15 Dec 2025 Sundeep Ghuman · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 7 Failure to take robust action and formal measures in response to widespread Spice use View source Lack of staff training and operational understanding of the CSRA policy View source Lack of assessment of Spice-related risks in cell-sharing decisions View source Lack of structured staff training on treatment of active racism alerts during cell-sharing assessments View source Failure to monitor CSRA policy implementation View source Failure to take robust action and formal measures in response to widespread prisoner-on-prisoner violence View source Failure to consider risks beyond the minimum CSRA when allocating prisoners to share a cell View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Sundeep Ghuman · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Sundeep Ghuman was a prisoner at HMP Belmarsh who was placed in a triple cell with a prisoner known to have racist and violent behaviour. On 18 February 2020, that prisoner violently assaulted Mr Ghuman with a table leg, and Mr Ghuman died in hospital on 19 February 2020 from a head injury. The principal concerns included failures in the CSRA process and training, inadequate treatment of racism alerts and other risk information, insufficient consideration of risks when allocating cellmates, and wider concerns about violence and drug use at HMP Belmarsh.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Belmarsh Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to take robust action and formal measures in response to widespread Spice use
Wider context from the report “The evidence overall was that HMP Belmarsh has widespread levels of violence by prisoners against other prisoners, and seemingly ubiquitous levels of Spice use in the prison . This seems to be at a level where staff do not consider that they can always take robust action and formal measures when this occurs . In those circumstances, I have a concern that the Prison may not currently be capable of providing a safe and secure environment for prisoners accommodated there, and that there is a risk of future deaths from drug use or violence .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Belmarsh Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of staff training and operational understanding of the CSRA policy
Wider context from the report “In addition, the lack of understanding of the policy by all staff (including senior management) at HMP Belmarsh appears to reflect a systemic failing of training and operational understanding , and a disconnect between those responsible for creating and maintaining the policy and those taking operational decisions within prisons. The fact that the comprehensive misunderstanding of the policy by HMP Belmarsh over a period of many years was entirely unknown to those responsible for the policy, even in circumstances where HMP Belmarsh operated its own system (complete with bespoke “S1” stickers) and not picked up by any audit or monitoring procedure also indicates a failure in policy implementation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Belmarsh Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of assessment of Spice-related risks in cell-sharing decisions
Wider context from the report “There appears to be no consideration in HMPPS of the risks to prisoners from inhalation of Spice when a cellmate is a user or supplier , or of the risks of more easily exploited prisoners being led into Spice use by cellmates who use the drug, and no assessment of whether it is safe to place a prisoner in a cell with a user or supplier of Spice .
I am aware that deaths have been directly linked to Spice use. In the absence of any assessment of the risks in individual cases, there appears to be a risk of death of a prisoner through being placed into a cell with a known user or supplier of Spice .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Belmarsh Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of structured staff training on treatment of active racism alerts during cell-sharing assessments
Wider context from the report “The lack of understanding of how an active alert for racism should be approached when assessing suitability sharing creates a risk of future fatal events. An unstructured approach and lack of training creates a risk that, as in this case, staff may inappropriately disregard an active alert for racism , leading to potentially fatal racist violence.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Belmarsh Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to monitor CSRA policy implementation
Wider context from the report “In addition, the lack of understanding of the policy by all staff (including senior management) at HMP Belmarsh appears to reflect a systemic failing of training and operational understanding, and a disconnect between those responsible for creating and maintaining the policy and those taking operational decisions within prisons. The fact that the comprehensive misunderstanding of the policy by HMP Belmarsh over a period of many years was entirely unknown to those responsible for the policy, even in circumstances where HMP Belmarsh operated its own system (complete with bespoke “S1” stickers) and not picked up by any audit or monitoring procedure also indicates a failure in policy implementation .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Belmarsh Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to take robust action and formal measures in response to widespread prisoner-on-prisoner violence
Wider context from the report “The evidence overall was that HMP Belmarsh has widespread levels of violence by prisoners against other prisoners , and seemingly ubiquitous levels of Spice use in the prison. This seems to be at a level where staff do not consider that they can always take robust action and formal measures when this occurs . In those circumstances, I have a concern that the Prison may not currently be capable of providing a safe and secure environment for prisoners accommodated there, and that there is a risk of future deaths from drug use or violence .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Belmarsh Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to consider risks beyond the minimum CSRA when allocating prisoners to share a cell
Wider context from the report “The evidence of staff at HMP Belmarsh (including from the Head of Security and Intelligence) was by contrast to the effect that moving into a cell are simply a daily occurrence and that as long as a CSRA says the individuals concerned can share then they can be moved in , and that no further consideration is necessary or appropriate . Consistently with this, the evidence of officers was that when arranging a cell move they would not look at the NOMIS notes of a prisoner, or other records, but solely at the CSRA to check that they were not High Risk (or “S1”).
” Open source report
3 Oct 2023 Manoel Messias Santos · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 10 Failure to provide timely notification of immigration detention before release View source Delays and failures by the SSHD in progressing FNO cases and obtaining required information View source Delays by probation in allocating community offender managers and providing up-to-date OASYS reports View source Absence of a prison offender manager specialist model for FNO immigration liaison View source Failure to facilitate and signpost access to immigration legal advice View source Failure of communication between immigration and sentence-planning agencies View source Persistent misunderstanding of the policy governing OSG officers opening cell doors at night View source Insufficient communication of entitlement to free immigration legal advice View source Lack of clear systems for obtaining medical information View source Failure to disseminate and action important learning points View source See 7 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Manoel Messias Santos · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Manoel Messias Santos, a Brazilian national detained in prison and facing immigration detention and possible deportation, was found hanging in his cell in the early hours of 2 November 2020 and was declared dead at 3.30am. The jury found that his understanding of his immigration position made a material contribution to his death and identified failures in notifying him about the IS91 notice and communicating his immigration position. The report also raised concerns about delays in notification and case handling, access to legal advice, communication between agencies, dissemination of learning, and staff understanding of the policy on opening cell doors at night.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Belmarsh Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to provide timely notification of immigration detention before release
Wider context from the report “2. The timing of the notification to Mr Santos by the SSHD that he was not to be released at the end of his custodial sentence but was to be held on immigration detention pending a decision on deportation. The SSHD target for notification is 30 days prior to release. In this case it was 8 days late. I heard PFD evidence that this 30-day target is not met in 40% of cases and that 83% of cases are notified within 7 days of the end of the sentence . I am concerned at the potential uncertainty and distress caused to Foreign National Offenders (“FNOs”) by notification at this stage.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Belmarsh Prison; that does not assign responsibility.
PFD Monitor interpretation Delays and failures by the SSHD in progressing FNO cases and obtaining required information
Wider context from the report “8. I am concerned at the potential impact of delays/failure to obtain information in other cases. In Mr Santos’ case there were delays by probation in allocating a community offender manager and providing an up-to-date OASYS report. There were also delays by the SSHD progressing Mr Santos’ case , including issue of the Stage 2 letter , failure to obtain medical records and delay in requesting the OASYS report .
9. I am encouraged that there is now a centralised system (and form) for the SSHD to request OASYS reports from probation although it is not clear the extent to which requests are going through this system. Consent to obtain medical information is sought from FNOs at an induction meeting by Immigration Prison Teams (“IPTs”). Further IPT officers attend prisons and play a key role in obtaining this type of information. However it is not clear what systems are in place to facilitate the obtaining of medical information.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Belmarsh Prison; that does not assign responsibility.
PFD Monitor interpretation Delays by probation in allocating community offender managers and providing up-to-date OASYS reports
Wider context from the report “8. I am concerned at the potential impact of delays/failure to obtain information in other cases. In Mr Santos’ case there were delays by probation in allocating a community offender manager and providing an up-to-date OASYS report . There were also delays by the SSHD progressing Mr Santos’ case, including issue of the Stage 2 letter, failure to obtain medical records and delay in requesting the OASYS report.
9. I am encouraged that there is now a centralised system (and form) for the SSHD to request OASYS reports from probation although it is not clear the extent to which requests are going through this system. Consent to obtain medical information is sought from FNOs at an induction meeting by Immigration Prison Teams (“IPTs”). Further IPT officers attend prisons and play a key role in obtaining this type of information. However it is not clear what systems are in place to facilitate the obtaining of medical information.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Belmarsh Prison; that does not assign responsibility.
PFD Monitor interpretation Absence of a prison offender manager specialist model for FNO immigration liaison
Wider context from the report “6. Communication issues between the agencies dealing with immigration and sentence planning may lead to confusion and uncertainty for FNOs.
7. I appreciate that any legal advice for FNOs should be from a legal adviser. I am encouraged that the probation service (who employ community offender managers) is seeking to develop a cohort of probation officers specialising in FNOs and immigration. There are now 201 SPOCs across 12 regions and a hub lead developing this model and leading engagement with the SSHD. There is no such model in the prison in respect of “prison offender managers” who also liaise with the SSHD about FNOs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Belmarsh Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to facilitate and signpost access to immigration legal advice
Wider context from the report “4. I am concerned as to how access to legal advice is facilitated and signposted.
5. In PFD evidence, I was informed that FNOs (in a similar position to Mr Santos) are now entitled to 30 minutes of free legal advice following a High Court decision in February 2021. In HMP Belmarsh, this entitlement is displayed on a notice in each Houseblock. I am concerned that displaying a notice is insufficient to draw this entitlement to the attention of FNOs. I do not know if this is a wider issue in other prisons. Understanding of immigration status, including appeal and bail procedures and is complex. Access to legal advice is vital to prevent confusion.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Belmarsh Prison; that does not assign responsibility.
PFD Monitor interpretation Failure of communication between immigration and sentence-planning agencies
Wider context from the report “6. Communication issues between the agencies dealing with immigration and sentence planning may lead to confusion and uncertainty for FNOs.
7. I appreciate that any legal advice for FNOs should be from a legal adviser. I am encouraged that the probation service (who employ community offender managers) is seeking to develop a cohort of probation officers specialising in FNOs and immigration. There are now 201 SPOCs across 12 regions and a hub lead developing this model and leading engagement with the SSHD. There is no such model in the prison in respect of “prison offender managers” who also liaise with the SSHD about FNOs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Belmarsh Prison; that does not assign responsibility.
PFD Monitor interpretation Persistent misunderstanding of the policy governing OSG officers opening cell doors at night
Wider context from the report “13. In evidence there was a continued misunderstanding that the policy did not apply to Operational Support Grade (OSG) officers and it was understood that they should never open cell doors at night . This was despite the PPO report dated December 2021 (at paragraph 73) requesting this be addressed.
14. The prison stated in PFD evidence that all staff will be instructed as to the policy in terms of opening cell doors at night (which requires a dynamic risk assessment).
15. I remain concerned that this appears to be a longstanding belief held by experienced officers .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Belmarsh Prison; that does not assign responsibility.
PFD Monitor interpretation Insufficient communication of entitlement to free immigration legal advice
Wider context from the report “4. I am concerned as to how access to legal advice is facilitated and signposted.
5. In PFD evidence, I was informed that FNOs (in a similar position to Mr Santos) are now entitled to 30 minutes of free legal advice following a High Court decision in February 2021. In HMP Belmarsh, this entitlement is displayed on a notice in each Houseblock. I am concerned that displaying a notice is insufficient to draw this entitlement to the attention of FNOs. I do not know if this is a wider issue in other prisons. Understanding of immigration status, including appeal and bail procedures and is complex. Access to legal advice is vital to prevent confusion.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Belmarsh Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of clear systems for obtaining medical information
Wider context from the report “8. I am concerned at the potential impact of delays/failure to obtain information in other cases. In Mr Santos’ case there were delays by probation in allocating a community offender manager and providing an up-to-date OASYS report. There were also delays by the SSHD progressing Mr Santos’ case, including issue of the Stage 2 letter, failure to obtain medical records and delay in requesting the OASYS report.
9. I am encouraged that there is now a centralised system (and form) for the SSHD to request OASYS reports from probation although it is not clear the extent to which requests are going through this system. Consent to obtain medical information is sought from FNOs at an induction meeting by Immigration Prison Teams (“IPTs”). Further IPT officers attend prisons and play a key role in obtaining this type of information. However it is not clear what systems are in place to facilitate the obtaining of medical information.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Belmarsh Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to disseminate and action important learning points
Wider context from the report “10. The SSHD disclosed an Internal report into Mr Santos’ case midway through the Inquest, which was not on his Home Office file. The lawyers representing the SSHD were unaware of this report. The head of FNO Returns Command only became aware of it the preceding week and understood it had been disclosed.
11. The report detailed delays and issues in Mr Santos’ case and the SSHD then made formal admissions of the relevant (non-causative) failures which where recorded by the jury in the Record of Inquest at my direction.
12. This report was dated February 2021 and listed action points for the relevant department. Although I am told that these are now being addressed, I am concerned that important learning points (which could prevent future deaths) were not disseminated and actioned as they should have been.
” Open source report
8 Nov 2022 Liridon Salikuка · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 2 Lack of disability awareness among prison staff View source Lack of accessible documentation of required disability adjustments View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Liridon Salikuка · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Liridon Saliuka was a remand prisoner at HMP Belmarsh who, after being moved from a medical cell to an ordinary cell without a special bed or mattress, hung himself in his cell on 2 January 2020. The report identified failures to recognise and accommodate his disability, inadequate care coordination and record keeping, and discriminatory and dismissive treatment. It also raised concerns about the lack of clear documentation of required adjustments and insufficient disability awareness among prison staff.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Belmarsh Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of disability awareness among prison staff
Wider context from the report “2. To the Governor of Belmarsh. There was a lack of disability awareness amongst prison staff of all levels . For example, there was an assumption that a prisoner could not be disabled because he used the gym and had good upper body strength .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Belmarsh Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of accessible documentation of required disability adjustments
Wider context from the report “1. To the Governor of Belmarsh and to the Chief Executive of Oxleas. There was no clear documentation (accessible by prison staff, healthcare and social services) of the adjustments that were required for the prisoner’s disability ,
” Open source report
30 Sep 2021 Stephen David COPE · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 2 Premature closure of ACCTs for newly transferred prisoners before sufficient review, assessment and communication View source ACCT closure criteria being vulnerable to manipulation through two negative prisoner responses View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Stephen David COPE · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Stephen David Cope died by suspension in his own cell block at Belmarsh prison on 18 November 2019. The principal concern was the transfer and review of prisoners on an ACCT, particularly the closure of an ACCT shortly after a prisoner’s transfer before support services had sufficient time to assess and communicate about them.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Belmarsh Prison; that does not assign responsibility.
PFD Monitor interpretation Premature closure of ACCTs for newly transferred prisoners before sufficient review, assessment and communication
Wider context from the report “(1) The transfer and review of prisoners on an ACCT.
I am concerned in relation to the ability of any Prison to close an ACCT, with the attendance of 2 individuals (a prison and health care staff), after a short period of time on a newly transferred inmate (i.e. to a new prison) before anyone has had the time to review and assess him or her .
For ACCTs created on current inmates within an establishment, who are known to staff, I do not see that as an issue, they would already have an existing knowledge and relationship and indeed would have been the originator of the ACCT in any event.
However, for new prisoners, who have arrived from another prison establishment with an open ACCT on their record, I consider the ability to remove that individual from the ACCT, within a short period of time, does raise issues in respect of the knowledge and understanding of that individual and the ability of various agencies, within the prison, to have had time to review and communicate between themselves, about that individual .
The provision of in effect 2 ‘no’ answers by a prisoner, is a potentially easy way of coming off an ACCT, which is there for their support and well-being, and I would suggest, given to easy manipulation
I raise the issue as to whether there should be, for example, a set review period (e.g. 7 days) which allows time for the support services to meet with and interview the transferred inmate, interact, and then make a decision about and with the newly transferred prisoner on the ACCT before such an ACCT is closed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Belmarsh Prison; that does not assign responsibility.
PFD Monitor interpretation ACCT closure criteria being vulnerable to manipulation through two negative prisoner responses
Wider context from the report “(1) The transfer and review of prisoners on an ACCT.
I am concerned in relation to the ability of any Prison to close an ACCT, with the attendance of 2 individuals (a prison and health care staff), after a short period of time on a newly transferred inmate (i.e. to a new prison) before anyone has had the time to review and assess him or her.
For ACCTs created on current inmates within an establishment, who are known to staff, I do not see that as an issue, they would already have an existing knowledge and relationship and indeed would have been the originator of the ACCT in any event.
However, for new prisoners, who have arrived from another prison establishment with an open ACCT on their record, I consider the ability to remove that individual from the ACCT, within a short period of time, does raise issues in respect of the knowledge and understanding of that individual and the ability of various agencies, within the prison, to have had time to review and communicate between themselves, about that individual.
The provision of in effect 2 ‘no’ answers by a prisoner, is a potentially easy way of coming off an ACCT , which is there for their support and well-being, and I would suggest, given to easy manipulation
I raise the issue as to whether there should be, for example, a set review period (e.g. 7 days) which allows time for the support services to meet with and interview the transferred inmate, interact, and then make a decision about and with the newly transferred prisoner on the ACCT before such an ACCT is closed.
” Open source report
10 Feb 2021 Jason O’Rourke · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 3 Failure of the prisoner arrival form to sufficiently highlight self-harm and suicide risk to wing staff View source Lack of robust management audit of nightly roll checks View source Failure of the prisoner arrival form to provide a clear self-harm and suicide risk assessment and response pathway View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Jason O’Rourke · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Jason O’Rourke died by suicide in his cell at HMP Belmarsh after hanging himself with a bedsheet ligature between 7.28 pm on 1 April 2019 and 9.33 am on 2 April 2019. The jury identified possible contributing factors including inadequate follow-up of his mental health, insufficient sharing and understanding of information about his mental health and self-harm history, and inadequate safety intervention meetings. The report also raised concerns about unclear self-harm and suicide risk assessments on arrival and the lack of robust auditing of nightly roll checks.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Belmarsh Prison; that does not assign responsibility.
PFD Monitor interpretation Failure of the prisoner arrival form to sufficiently highlight self-harm and suicide risk to wing staff
Wider context from the report “(1) The ‘immediate needs’ form completed for prisoners on arrival at HMP Belmarsh does not facilitate a clear assessment of any risk of self-harm or suicide and the actions to be taken if such a risk is identified.
The form poses a question: “Is there any specific concerns re self-harm or suicide?” and then gives the guidance “if yes, amend care plan”. However, this guidance is only effective for those prisoners who already have a care plan, meaning those who are already on an Open Assessment, Care in Custody and Teamwork (‘ACCT’) plan. The action to be taken for those prisoners where specific concerns regarding self-harm or suicide are identified, but who do not already have a care plan, is unclear from the form.
It is also unclear how the above question interacts with further questions below it which address any past ACCTs/F2052SHs, the level of support available to the prisoner and the answer the prisoner gives to the question “Do you feel suicidal now?”
Accordingly, this form does not sufficiently highlight prisoners who are in fact suicidal, or where there are concerns about their risk of self-harm or suicidal, to those on the wing.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Belmarsh Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of robust management audit of nightly roll checks
Wider context from the report “(2) The nightly roll checks at HMP Belmarsh are due to be carried out by a single member of Operational Support Grade (OSG) staff at 9.00 pm and 6.00 am. Their stated purpose is to check for escape or death among the prisoners. On handing over to the morning staff, the OSG signs paperwork indicating that the roll checks have been completed. There is no robust system by which the prison management audit this process. This means that the prison management can be under the impression that the checks have been carried out, when they have not been , as occurred here.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Belmarsh Prison; that does not assign responsibility.
PFD Monitor interpretation Failure of the prisoner arrival form to provide a clear self-harm and suicide risk assessment and response pathway
Wider context from the report “(1) The ‘immediate needs’ form completed for prisoners on arrival at HMP Belmarsh does not facilitate a clear assessment of any risk of self-harm or suicide and the actions to be taken if such a risk is identified .
The form poses a question: “Is there any specific concerns re self-harm or suicide?” and then gives the guidance “if yes, amend care plan”. However, this guidance is only effective for those prisoners who already have a care plan, meaning those who are already on an Open Assessment, Care in Custody and Teamwork (‘ACCT’) plan. The action to be taken for those prisoners where specific concerns regarding self-harm or suicide are identified, but who do not already have a care plan, is unclear from the form.
It is also unclear how the above question interacts with further questions below it which address any past ACCTs/F2052SHs, the level of support available to the prisoner and the answer the prisoner gives to the question “Do you feel suicidal now?”
Accordingly, this form does not sufficiently highlight prisoners who are in fact suicidal, or where there are concerns about their risk of self-harm or suicidal, to those on the wing.
” Open source report
22 Apr 2015 Laurence Boyens · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 12 Failure to recognise appropriate indications for Naloxone administration View source Failure to communicate and define reporting parameters for pre-administration blood-pressure readings View source Failure to record respiratory rates when monitoring controlled-drug patients View source Failure to cancel discontinued medication prescriptions in the computerised record View source Failure to record blood-pressure readings promptly in medical records View source Failure to identify and act on drowsiness before controlled-drug administration View source Failure to stop medicines when Methadone toxicity is considered View source Failure to review blood-pressure trends before controlled-drug administration View source Failure to suspend controlled drugs and escalate low blood pressure View source Lack of defined criteria and recording requirements for lowering blood pressure View source Prescribing multiple medicines without a sufficiently complete clinical assessment and medication history View source Failure to assess drug interactions and cumulative effects before prescribing View source See 9 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Laurence Boyens · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Laurence Boyens died in prison on 15 November 2012 from Methadone, Tramadol and Diazepam intoxication. The jury identified concerns about the combination and interaction of prescribed drugs, failures to monitor intoxication symptoms and blood pressure, and failures to suspend or withhold Methadone and Tramadol when signs of toxicity were present.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Belmarsh Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise appropriate indications for Naloxone administration
Wider context from the report “4. ████████
████████ was represented at the inquest and the following evidence gave rise to concerns:
• He prescribed Citalopram, Tramadol, Methadone, Diazepam and Sodium Valproate on 10th to a new patient without seeing him, although probably in possession of old medical records from previous stay in prison, but not those from his GP related to the period before detention in prison.
• When he saw the patient on 13th he failed to consider the interactions between Citalopram and Tramadol and between Citalopram and Methadone, both of which the prison expert ████████ said were contraindicated, nor the summative effects of combining Methadone, Tramadol and Diazepam.
• He said that he was not aware whether withdrawal can cause low BP and thought the BP was measured to see if the patient was withdrawing.
• He said that he did not know whether he should stop Methadone if the BP was low.
• Mr Boyens was seen by the doctor on 13th, the day after another witness found him drowsy with “pinned eyes” and a few hours before another witness found him unsteady and drowsy. He made no record of the state of the pupils, but did record him as unusually drowsy.
• At that examination, according to his 2013 statement he considered the patient was drowsy due to lack of sleep; in a 2015 statement he considered use of illicit drugs and was aware of the possibility of Methadone toxicity. But he failed to stop these drugs from continuing to be administered.
• At this assessment on 13th he recorded an intention to stop the Citalopram on the request of the patient, but did not take the simple steps to cancel the prescription on the computerised record and if he told a nurse about this instruction it was not recalled or noted by them, and continued to be administered.
• He gave evidence that he would not administer Naloxone to a patient unless the patient was blue and unconscious and known to have taken opiates and did not know any disadvantages of doing so . ████████ gave evidence that this was not correct and that Naloxone properly administered had the potential to save lives.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Belmarsh Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate and define reporting parameters for pre-administration blood-pressure readings
Wider context from the report “1. There appeared to be a general misunderstanding how health care professionals should comply with DH Clinical Management of Drug Dependence in Adult Prison Settings Guidelines 12.3 and 12.4. In particular this relates to the requirement to ensure that patients who are undergoing Methadone or Buprenorphine stabilization have not experienced a lowering of blood pressure or drowsiness before administration of the controlled drug.
• Health care assistants routinely took the blood pressure before administration but did not inform the nurse of the reading and may not have had instruction when to report the reading
• The evidence of six nurses and a health care assistant showed that previous blood pressure recordings were not sought or examined to determine if there had been a lowering of BP
• The record of blood pressure was often written on paper and not usually entered in the medical records at the time and sometimes not at all
• A health care assistant who did record a BP of 93/68 was asked by a nurse to repeat it and reported back to the medication hatch that it was still low. No apparent action was taken by nurses to suspend the medication or escalate the concern to a doctor on 11th.
• One nurse, who did not see the BP of 93/58 recorded in the records and administered Methadone, did not know what she would do if he had discovered a previous higher BP.
• One nurse was surprised that a BP of 105/60 having a reading of 128/68 and 93/68 the previous day and 121/81 the day before that, should trigger withholding Methadone and escalating to the doctor.
• The expert GP, who had been clinical director in the health care team provided to the prison, identified a sequence of seven BP recordings over 4 days, six of which (the second was considered rogue) should have triggered suspension of administration of drugs and escalation to the doctor, but in no case did this occur.
• The head of health care at the time, who was an inexperienced nurse, did not accept that advice and asserted it would be impractical to implement it, as it would lead to significant delays.
• In a local policy on Buprenorphine a threshold triggering suspension of drug and escalation was defined as 90/60 without reference to the trend. None was found in a section on Methadone and no definition of lowering of blood pressure or how to record it was found in any local policies.
• No nurse saw the entry in the medical records by a doctor at 18.56 on 13th November which read: “Unusually drowsy. Eyelids close when not engaged. communicative alert. no sadness or dsh. Plan stop Citalopram and monitor for signs of overdose.. may req further urine test before further Methadone testing...”.
• At 17.57 on 13th, one hour from the doctor’s assessment, when he must have been unusually drowsy, no nurse found him drowsy when he presented at the hatch for medication, and he was given Methadone and Tramadol.
• On the morning of 14th he was given further Methadone and Tramadol, without measuring the blood pressure, or testing, as the previous day was last day of his Methadone titration regime and his 5 day review.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Belmarsh Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to record respiratory rates when monitoring controlled-drug patients
Wider context from the report “3. Nurse ████████ was called during the course of the inquest, and although given the opportunity, did not have legal representation in the proceedings.
The evidence from Nurse ████████ herself that caused concern about risks to future patients included:
• She did not record a BP at 18.35 on 10th, or at 09.25 on 11th, prior to administration of Methadone.
• She did not notice a BP of 93/68 recorded on “System One” at 15.27, before she administered Methadone at 17.50 on 11th.
• She expected the health care assistant to inform her of an abnormal blood pressure, but has not set any parameters, prior to Methadone
• She never looked at previous blood pressures prior to administering Methadone.
• She never makes respiratory rate recordings in monitoring patients on controlled drugs
• If she had seen the blood pressure of 134/113 that was recorded at 09.21 on 12th November, she would not do anything different.
• Given that her drug administration clinics were very busy (60 people per session), she was asked whether it would make any difference to what she did, if she saw half as many patients, but she said she would still not look at the blood pressures.
• Asked if she had changed her practice in any way since the incident, she said that she had not.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Belmarsh Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to cancel discontinued medication prescriptions in the computerised record
Wider context from the report “4. ████████
████████ was represented at the inquest and the following evidence gave rise to concerns:
• He prescribed Citalopram, Tramadol, Methadone, Diazepam and Sodium Valproate on 10th to a new patient without seeing him, although probably in possession of old medical records from previous stay in prison, but not those from his GP related to the period before detention in prison.
• When he saw the patient on 13th he failed to consider the interactions between Citalopram and Tramadol and between Citalopram and Methadone, both of which the prison expert ████████ said were contraindicated, nor the summative effects of combining Methadone, Tramadol and Diazepam.
• He said that he was not aware whether withdrawal can cause low BP and thought the BP was measured to see if the patient was withdrawing.
• He said that he did not know whether he should stop Methadone if the BP was low.
• Mr Boyens was seen by the doctor on 13th, the day after another witness found him drowsy with “pinned eyes” and a few hours before another witness found him unsteady and drowsy. He made no record of the state of the pupils, but did record him as unusually drowsy.
• At that examination, according to his 2013 statement he considered the patient was drowsy due to lack of sleep; in a 2015 statement he considered use of illicit drugs and was aware of the possibility of Methadone toxicity. But he failed to stop these drugs from continuing to be administered.
• At this assessment on 13th he recorded an intention to stop the Citalopram on the request of the patient, but did not take the simple steps to cancel the prescription on the computerised record and if he told a nurse about this instruction it was not recalled or noted by them, and continued to be administered .
• He gave evidence that he would not administer Naloxone to a patient unless the patient was blue and unconscious and known to have taken opiates and did not know any disadvantages of doing so. ████████ gave evidence that this was not correct and that Naloxone properly administered had the potential to save lives.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Belmarsh Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to record blood-pressure readings promptly in medical records
Wider context from the report “1. There appeared to be a general misunderstanding how health care professionals should comply with DH Clinical Management of Drug Dependence in Adult Prison Settings Guidelines 12.3 and 12.4. In particular this relates to the requirement to ensure that patients who are undergoing Methadone or Buprenorphine stabilization have not experienced a lowering of blood pressure or drowsiness before administration of the controlled drug.
• Health care assistants routinely took the blood pressure before administration but did not inform the nurse of the reading and may not have had instruction when to report the reading
• The evidence of six nurses and a health care assistant showed that previous blood pressure recordings were not sought or examined to determine if there had been a lowering of BP
• The record of blood pressure was often written on paper and not usually entered in the medical records at the time and sometimes not at all
• A health care assistant who did record a BP of 93/68 was asked by a nurse to repeat it and reported back to the medication hatch that it was still low. No apparent action was taken by nurses to suspend the medication or escalate the concern to a doctor on 11th.
• One nurse, who did not see the BP of 93/58 recorded in the records and administered Methadone, did not know what she would do if he had discovered a previous higher BP.
• One nurse was surprised that a BP of 105/60 having a reading of 128/68 and 93/68 the previous day and 121/81 the day before that, should trigger withholding Methadone and escalating to the doctor.
• The expert GP, who had been clinical director in the health care team provided to the prison, identified a sequence of seven BP recordings over 4 days, six of which (the second was considered rogue) should have triggered suspension of administration of drugs and escalation to the doctor, but in no case did this occur.
• The head of health care at the time, who was an inexperienced nurse, did not accept that advice and asserted it would be impractical to implement it, as it would lead to significant delays.
• In a local policy on Buprenorphine a threshold triggering suspension of drug and escalation was defined as 90/60 without reference to the trend. None was found in a section on Methadone and no definition of lowering of blood pressure or how to record it was found in any local policies.
• No nurse saw the entry in the medical records by a doctor at 18.56 on 13th November which read: “Unusually drowsy. Eyelids close when not engaged. communicative alert. no sadness or dsh. Plan stop Citalopram and monitor for signs of overdose.. may req further urine test before further Methadone testing...”.
• At 17.57 on 13th, one hour from the doctor’s assessment, when he must have been unusually drowsy, no nurse found him drowsy when he presented at the hatch for medication, and he was given Methadone and Tramadol.
• On the morning of 14th he was given further Methadone and Tramadol, without measuring the blood pressure, or testing, as the previous day was last day of his Methadone titration regime and his 5 day review.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Belmarsh Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to identify and act on drowsiness before controlled-drug administration
Wider context from the report “1. There appeared to be a general misunderstanding how health care professionals should comply with DH Clinical Management of Drug Dependence in Adult Prison Settings Guidelines 12.3 and 12.4. In particular this relates to the requirement to ensure that patients who are undergoing Methadone or Buprenorphine stabilization have not experienced a lowering of blood pressure or drowsiness before administration of the controlled drug.
• Health care assistants routinely took the blood pressure before administration but did not inform the nurse of the reading and may not have had instruction when to report the reading
• The evidence of six nurses and a health care assistant showed that previous blood pressure recordings were not sought or examined to determine if there had been a lowering of BP
• The record of blood pressure was often written on paper and not usually entered in the medical records at the time and sometimes not at all
• A health care assistant who did record a BP of 93/68 was asked by a nurse to repeat it and reported back to the medication hatch that it was still low. No apparent action was taken by nurses to suspend the medication or escalate the concern to a doctor on 11th.
• One nurse, who did not see the BP of 93/58 recorded in the records and administered Methadone, did not know what she would do if he had discovered a previous higher BP.
• One nurse was surprised that a BP of 105/60 having a reading of 128/68 and 93/68 the previous day and 121/81 the day before that, should trigger withholding Methadone and escalating to the doctor.
• The expert GP, who had been clinical director in the health care team provided to the prison, identified a sequence of seven BP recordings over 4 days, six of which (the second was considered rogue) should have triggered suspension of administration of drugs and escalation to the doctor, but in no case did this occur.
• The head of health care at the time, who was an inexperienced nurse, did not accept that advice and asserted it would be impractical to implement it, as it would lead to significant delays.
• In a local policy on Buprenorphine a threshold triggering suspension of drug and escalation was defined as 90/60 without reference to the trend. None was found in a section on Methadone and no definition of lowering of blood pressure or how to record it was found in any local policies.
• No nurse saw the entry in the medical records by a doctor at 18.56 on 13th November which read: “Unusually drowsy. Eyelids close when not engaged. communicative alert. no sadness or dsh. Plan stop Citalopram and monitor for signs of overdose.. may req further urine test before further Methadone testing...”.
• At 17.57 on 13th, one hour from the doctor’s assessment, when he must have been unusually drowsy, no nurse found him drowsy when he presented at the hatch for medication , and he was given Methadone and Tramadol.
• On the morning of 14th he was given further Methadone and Tramadol, without measuring the blood pressure, or testing, as the previous day was last day of his Methadone titration regime and his 5 day review.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Belmarsh Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to stop medicines when Methadone toxicity is considered
Wider context from the report “4. ████████
████████ was represented at the inquest and the following evidence gave rise to concerns:
• He prescribed Citalopram, Tramadol, Methadone, Diazepam and Sodium Valproate on 10th to a new patient without seeing him, although probably in possession of old medical records from previous stay in prison, but not those from his GP related to the period before detention in prison.
• When he saw the patient on 13th he failed to consider the interactions between Citalopram and Tramadol and between Citalopram and Methadone, both of which the prison expert ████████ said were contraindicated, nor the summative effects of combining Methadone, Tramadol and Diazepam.
• He said that he was not aware whether withdrawal can cause low BP and thought the BP was measured to see if the patient was withdrawing.
• He said that he did not know whether he should stop Methadone if the BP was low.
• Mr Boyens was seen by the doctor on 13th, the day after another witness found him drowsy with “pinned eyes” and a few hours before another witness found him unsteady and drowsy. He made no record of the state of the pupils, but did record him as unusually drowsy.
• At that examination, according to his 2013 statement he considered the patient was drowsy due to lack of sleep; in a 2015 statement he considered use of illicit drugs and was aware of the possibility of Methadone toxicity. But he failed to stop these drugs from continuing to be administered .
• At this assessment on 13th he recorded an intention to stop the Citalopram on the request of the patient, but did not take the simple steps to cancel the prescription on the computerised record and if he told a nurse about this instruction it was not recalled or noted by them, and continued to be administered.
• He gave evidence that he would not administer Naloxone to a patient unless the patient was blue and unconscious and known to have taken opiates and did not know any disadvantages of doing so. ████████ gave evidence that this was not correct and that Naloxone properly administered had the potential to save lives.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Belmarsh Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to review blood-pressure trends before controlled-drug administration
Wider context from the report “1. There appeared to be a general misunderstanding how health care professionals should comply with DH Clinical Management of Drug Dependence in Adult Prison Settings Guidelines 12.3 and 12.4. In particular this relates to the requirement to ensure that patients who are undergoing Methadone or Buprenorphine stabilization have not experienced a lowering of blood pressure or drowsiness before administration of the controlled drug.
• Health care assistants routinely took the blood pressure before administration but did not inform the nurse of the reading and may not have had instruction when to report the reading
• The evidence of six nurses and a health care assistant showed that previous blood pressure recordings were not sought or examined to determine if there had been a lowering of BP
• The record of blood pressure was often written on paper and not usually entered in the medical records at the time and sometimes not at all
• A health care assistant who did record a BP of 93/68 was asked by a nurse to repeat it and reported back to the medication hatch that it was still low. No apparent action was taken by nurses to suspend the medication or escalate the concern to a doctor on 11th.
• One nurse, who did not see the BP of 93/58 recorded in the records and administered Methadone, did not know what she would do if he had discovered a previous higher BP.
• One nurse was surprised that a BP of 105/60 having a reading of 128/68 and 93/68 the previous day and 121/81 the day before that, should trigger withholding Methadone and escalating to the doctor.
• The expert GP, who had been clinical director in the health care team provided to the prison, identified a sequence of seven BP recordings over 4 days, six of which (the second was considered rogue) should have triggered suspension of administration of drugs and escalation to the doctor, but in no case did this occur.
• The head of health care at the time, who was an inexperienced nurse, did not accept that advice and asserted it would be impractical to implement it, as it would lead to significant delays.
• In a local policy on Buprenorphine a threshold triggering suspension of drug and escalation was defined as 90/60 without reference to the trend. None was found in a section on Methadone and no definition of lowering of blood pressure or how to record it was found in any local policies.
• No nurse saw the entry in the medical records by a doctor at 18.56 on 13th November which read: “Unusually drowsy. Eyelids close when not engaged. communicative alert. no sadness or dsh. Plan stop Citalopram and monitor for signs of overdose.. may req further urine test before further Methadone testing...”.
• At 17.57 on 13th, one hour from the doctor’s assessment, when he must have been unusually drowsy, no nurse found him drowsy when he presented at the hatch for medication, and he was given Methadone and Tramadol.
• On the morning of 14th he was given further Methadone and Tramadol, without measuring the blood pressure, or testing, as the previous day was last day of his Methadone titration regime and his 5 day review.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Belmarsh Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to suspend controlled drugs and escalate low blood pressure
Wider context from the report “1. There appeared to be a general misunderstanding how health care professionals should comply with DH Clinical Management of Drug Dependence in Adult Prison Settings Guidelines 12.3 and 12.4. In particular this relates to the requirement to ensure that patients who are undergoing Methadone or Buprenorphine stabilization have not experienced a lowering of blood pressure or drowsiness before administration of the controlled drug.
• Health care assistants routinely took the blood pressure before administration but did not inform the nurse of the reading and may not have had instruction when to report the reading
• The evidence of six nurses and a health care assistant showed that previous blood pressure recordings were not sought or examined to determine if there had been a lowering of BP
• The record of blood pressure was often written on paper and not usually entered in the medical records at the time and sometimes not at all
• A health care assistant who did record a BP of 93/68 was asked by a nurse to repeat it and reported back to the medication hatch that it was still low. No apparent action was taken by nurses to suspend the medication or escalate the concern to a doctor on 11th.
• One nurse, who did not see the BP of 93/58 recorded in the records and administered Methadone, did not know what she would do if he had discovered a previous higher BP.
• One nurse was surprised that a BP of 105/60 having a reading of 128/68 and 93/68 the previous day and 121/81 the day before that, should trigger withholding Methadone and escalating to the doctor.
• The expert GP, who had been clinical director in the health care team provided to the prison, identified a sequence of seven BP recordings over 4 days, six of which (the second was considered rogue) should have triggered suspension of administration of drugs and escalation to the doctor, but in no case did this occur .
• The head of health care at the time, who was an inexperienced nurse, did not accept that advice and asserted it would be impractical to implement it, as it would lead to significant delays.
• In a local policy on Buprenorphine a threshold triggering suspension of drug and escalation was defined as 90/60 without reference to the trend. None was found in a section on Methadone and no definition of lowering of blood pressure or how to record it was found in any local policies.
• No nurse saw the entry in the medical records by a doctor at 18.56 on 13th November which read: “Unusually drowsy. Eyelids close when not engaged. communicative alert. no sadness or dsh. Plan stop Citalopram and monitor for signs of overdose.. may req further urine test before further Methadone testing...”.
• At 17.57 on 13th, one hour from the doctor’s assessment, when he must have been unusually drowsy, no nurse found him drowsy when he presented at the hatch for medication, and he was given Methadone and Tramadol.
• On the morning of 14th he was given further Methadone and Tramadol, without measuring the blood pressure, or testing, as the previous day was last day of his Methadone titration regime and his 5 day review.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Belmarsh Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of defined criteria and recording requirements for lowering blood pressure
Wider context from the report “1. There appeared to be a general misunderstanding how health care professionals should comply with DH Clinical Management of Drug Dependence in Adult Prison Settings Guidelines 12.3 and 12.4. In particular this relates to the requirement to ensure that patients who are undergoing Methadone or Buprenorphine stabilization have not experienced a lowering of blood pressure or drowsiness before administration of the controlled drug.
• Health care assistants routinely took the blood pressure before administration but did not inform the nurse of the reading and may not have had instruction when to report the reading
• The evidence of six nurses and a health care assistant showed that previous blood pressure recordings were not sought or examined to determine if there had been a lowering of BP
• The record of blood pressure was often written on paper and not usually entered in the medical records at the time and sometimes not at all
• A health care assistant who did record a BP of 93/68 was asked by a nurse to repeat it and reported back to the medication hatch that it was still low. No apparent action was taken by nurses to suspend the medication or escalate the concern to a doctor on 11th.
• One nurse, who did not see the BP of 93/58 recorded in the records and administered Methadone, did not know what she would do if he had discovered a previous higher BP.
• One nurse was surprised that a BP of 105/60 having a reading of 128/68 and 93/68 the previous day and 121/81 the day before that, should trigger withholding Methadone and escalating to the doctor.
• The expert GP, who had been clinical director in the health care team provided to the prison, identified a sequence of seven BP recordings over 4 days, six of which (the second was considered rogue) should have triggered suspension of administration of drugs and escalation to the doctor, but in no case did this occur.
• The head of health care at the time, who was an inexperienced nurse, did not accept that advice and asserted it would be impractical to implement it, as it would lead to significant delays.
• In a local policy on Buprenorphine a threshold triggering suspension of drug and escalation was defined as 90/60 without reference to the trend. None was found in a section on Methadone and no definition of lowering of blood pressure or how to record it was found in any local policies .
• No nurse saw the entry in the medical records by a doctor at 18.56 on 13th November which read: “Unusually drowsy. Eyelids close when not engaged. communicative alert. no sadness or dsh. Plan stop Citalopram and monitor for signs of overdose.. may req further urine test before further Methadone testing...”.
• At 17.57 on 13th, one hour from the doctor’s assessment, when he must have been unusually drowsy, no nurse found him drowsy when he presented at the hatch for medication, and he was given Methadone and Tramadol.
• On the morning of 14th he was given further Methadone and Tramadol, without measuring the blood pressure, or testing, as the previous day was last day of his Methadone titration regime and his 5 day review.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Belmarsh Prison; that does not assign responsibility.
PFD Monitor interpretation Prescribing multiple medicines without a sufficiently complete clinical assessment and medication history
Wider context from the report “4. ████████
████████ was represented at the inquest and the following evidence gave rise to concerns:
• He prescribed Citalopram, Tramadol, Methadone, Diazepam and Sodium Valproate on 10th to a new patient without seeing him , although probably in possession of old medical records from previous stay in prison, but not those from his GP related to the period before detention in prison .
• When he saw the patient on 13th he failed to consider the interactions between Citalopram and Tramadol and between Citalopram and Methadone, both of which the prison expert ████████ said were contraindicated, nor the summative effects of combining Methadone, Tramadol and Diazepam.
• He said that he was not aware whether withdrawal can cause low BP and thought the BP was measured to see if the patient was withdrawing.
• He said that he did not know whether he should stop Methadone if the BP was low.
• Mr Boyens was seen by the doctor on 13th, the day after another witness found him drowsy with “pinned eyes” and a few hours before another witness found him unsteady and drowsy. He made no record of the state of the pupils, but did record him as unusually drowsy.
• At that examination, according to his 2013 statement he considered the patient was drowsy due to lack of sleep; in a 2015 statement he considered use of illicit drugs and was aware of the possibility of Methadone toxicity. But he failed to stop these drugs from continuing to be administered.
• At this assessment on 13th he recorded an intention to stop the Citalopram on the request of the patient, but did not take the simple steps to cancel the prescription on the computerised record and if he told a nurse about this instruction it was not recalled or noted by them, and continued to be administered.
• He gave evidence that he would not administer Naloxone to a patient unless the patient was blue and unconscious and known to have taken opiates and did not know any disadvantages of doing so. ████████ gave evidence that this was not correct and that Naloxone properly administered had the potential to save lives.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Belmarsh Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to assess drug interactions and cumulative effects before prescribing
Wider context from the report “4. ████████
████████ was represented at the inquest and the following evidence gave rise to concerns:
• He prescribed Citalopram, Tramadol, Methadone, Diazepam and Sodium Valproate on 10th to a new patient without seeing him, although probably in possession of old medical records from previous stay in prison, but not those from his GP related to the period before detention in prison.
• When he saw the patient on 13th he failed to consider the interactions between Citalopram and Tramadol and between Citalopram and Methadone , both of which the prison expert ████████ said were contraindicated, nor the summative effects of combining Methadone, Tramadol and Diazepam .
• He said that he was not aware whether withdrawal can cause low BP and thought the BP was measured to see if the patient was withdrawing.
• He said that he did not know whether he should stop Methadone if the BP was low.
• Mr Boyens was seen by the doctor on 13th, the day after another witness found him drowsy with “pinned eyes” and a few hours before another witness found him unsteady and drowsy. He made no record of the state of the pupils, but did record him as unusually drowsy.
• At that examination, according to his 2013 statement he considered the patient was drowsy due to lack of sleep; in a 2015 statement he considered use of illicit drugs and was aware of the possibility of Methadone toxicity. But he failed to stop these drugs from continuing to be administered.
• At this assessment on 13th he recorded an intention to stop the Citalopram on the request of the patient, but did not take the simple steps to cancel the prescription on the computerised record and if he told a nurse about this instruction it was not recalled or noted by them, and continued to be administered.
• He gave evidence that he would not administer Naloxone to a patient unless the patient was blue and unconscious and known to have taken opiates and did not know any disadvantages of doing so. ████████ gave evidence that this was not correct and that Naloxone properly administered had the potential to save lives.
” Open source report
20 Dec 2013 Adrian Johnson · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 10 Failure to secure complete health care information for ACCT reviews View source Lack of health care staff training to manage tobacco withdrawal View source Inconsistent requests for members to attend ACCT reviews View source Failure to establish individual learning from ACCT review involvement View source Unclear responsibility for tobacco-withdrawal screening and management View source Failure to ensure fully informed decisions on reducing observations for vulnerable prisoners in the Segregation Unit View source Lack of health care staff training to conduct tobacco-withdrawal screening View source Failure to routinely screen and enquire into tobacco withdrawal during prison reception screening View source Inconsistent case management for prisoners moving to the Segregation Unit View source Inadequate caremap planning View source See 7 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Adrian Johnson · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Adrian Johnson died by an act of accidental hanging between 12.50 and 13.55 on 13 May 2010 in the Segregation Unit of HMP Belmarsh. The report identified failures in initial screening and ACCT review processes, including inadequate attention to mental health assessment, medication needs, nicotine dependency, clinical information and protection measures. Concerns remained about prison screening for tobacco withdrawal and the consistency and adequacy of ACCT case management and observation decisions for vulnerable prisoners.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Belmarsh Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to secure complete health care information for ACCT reviews
Wider context from the report “(1) Expert opinion has been given that the failure to routinely screen for and enquire into tobacco withdrawal as part of prison reception screening creates risks to the lives of a small number of vulnerable prisoners. Withdrawal problems may be interpreted by staff as behaviour designed to gain benefits, unless an appropriate health care assessment is conducted. Health care staff at HMP Belmarsh do not appear to be trained to conduct such screening, nor manage withdrawal, nor is it clear whose responsibility it would be.
(2) To questioning about steps that HMP had taken to reduce future risks, a governor reported a significant improvement in the conduct of ACCT reviews and pleasing spot checks. However she could not confirm whether there had been any individual learning by those involved. It was not clear that there would be any better consistency of case management in prisoners who move to the Segregation Unit, nor in the way in which members were asked to attend, nor the adequacy of caremap planning. The discipline staff appeared to blame the health care staff for the incomplete health care information at reviews , but there was no indication that they accepted that the case manager and chair had responsibilities to secure the information if it was not volunteered . It remained unclear how decisions on reduction of observations would in future be fully informed in exceptional cases where vulnerable prisoners are in the Segregation Unit. Improvements in the processes and conduct of ACCT reviews may not have fully addressed the areas of concern, which create significant risks for vulnerable prisoners
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Belmarsh Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of health care staff training to manage tobacco withdrawal
Wider context from the report “(1) Expert opinion has been given that the failure to routinely screen for and enquire into tobacco withdrawal as part of prison reception screening creates risks to the lives of a small number of vulnerable prisoners. Withdrawal problems may be interpreted by staff as behaviour designed to gain benefits, unless an appropriate health care assessment is conducted. Health care staff at HMP Belmarsh do not appear to be trained to conduct such screening, nor manage withdrawal , nor is it clear whose responsibility it would be.
(2) To questioning about steps that HMP had taken to reduce future risks, a governor reported a significant improvement in the conduct of ACCT reviews and pleasing spot checks. However she could not confirm whether there had been any individual learning by those involved. It was not clear that there would be any better consistency of case management in prisoners who move to the Segregation Unit, nor in the way in which members were asked to attend, nor the adequacy of caremap planning. The discipline staff appeared to blame the health care staff for the incomplete health care information at reviews, but there was no indication that they accepted that the case manager and chair had responsibilities to secure the information if it was not volunteered. It remained unclear how decisions on reduction of observations would in future be fully informed in exceptional cases where vulnerable prisoners are in the Segregation Unit. Improvements in the processes and conduct of ACCT reviews may not have fully addressed the areas of concern, which create significant risks for vulnerable prisoners
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Belmarsh Prison; that does not assign responsibility.
PFD Monitor interpretation Inconsistent requests for members to attend ACCT reviews
Wider context from the report “(1) Expert opinion has been given that the failure to routinely screen for and enquire into tobacco withdrawal as part of prison reception screening creates risks to the lives of a small number of vulnerable prisoners. Withdrawal problems may be interpreted by staff as behaviour designed to gain benefits, unless an appropriate health care assessment is conducted. Health care staff at HMP Belmarsh do not appear to be trained to conduct such screening, nor manage withdrawal, nor is it clear whose responsibility it would be.
(2) To questioning about steps that HMP had taken to reduce future risks, a governor reported a significant improvement in the conduct of ACCT reviews and pleasing spot checks. However she could not confirm whether there had been any individual learning by those involved. It was not clear that there would be any better consistency of case management in prisoners who move to the Segregation Unit, nor in the way in which members were asked to attend , nor the adequacy of caremap planning. The discipline staff appeared to blame the health care staff for the incomplete health care information at reviews, but there was no indication that they accepted that the case manager and chair had responsibilities to secure the information if it was not volunteered. It remained unclear how decisions on reduction of observations would in future be fully informed in exceptional cases where vulnerable prisoners are in the Segregation Unit. Improvements in the processes and conduct of ACCT reviews may not have fully addressed the areas of concern, which create significant risks for vulnerable prisoners
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Belmarsh Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to establish individual learning from ACCT review involvement
Wider context from the report “(1) Expert opinion has been given that the failure to routinely screen for and enquire into tobacco withdrawal as part of prison reception screening creates risks to the lives of a small number of vulnerable prisoners. Withdrawal problems may be interpreted by staff as behaviour designed to gain benefits, unless an appropriate health care assessment is conducted. Health care staff at HMP Belmarsh do not appear to be trained to conduct such screening, nor manage withdrawal, nor is it clear whose responsibility it would be.
(2) To questioning about steps that HMP had taken to reduce future risks, a governor reported a significant improvement in the conduct of ACCT reviews and pleasing spot checks. However she could not confirm whether there had been any individual learning by those involved . It was not clear that there would be any better consistency of case management in prisoners who move to the Segregation Unit, nor in the way in which members were asked to attend, nor the adequacy of caremap planning. The discipline staff appeared to blame the health care staff for the incomplete health care information at reviews, but there was no indication that they accepted that the case manager and chair had responsibilities to secure the information if it was not volunteered. It remained unclear how decisions on reduction of observations would in future be fully informed in exceptional cases where vulnerable prisoners are in the Segregation Unit. Improvements in the processes and conduct of ACCT reviews may not have fully addressed the areas of concern, which create significant risks for vulnerable prisoners
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Belmarsh Prison; that does not assign responsibility.
PFD Monitor interpretation Unclear responsibility for tobacco-withdrawal screening and management
Wider context from the report “(1) Expert opinion has been given that the failure to routinely screen for and enquire into tobacco withdrawal as part of prison reception screening creates risks to the lives of a small number of vulnerable prisoners. Withdrawal problems may be interpreted by staff as behaviour designed to gain benefits, unless an appropriate health care assessment is conducted. Health care staff at HMP Belmarsh do not appear to be trained to conduct such screening, nor manage withdrawal, nor is it clear whose responsibility it would be .
(2) To questioning about steps that HMP had taken to reduce future risks, a governor reported a significant improvement in the conduct of ACCT reviews and pleasing spot checks. However she could not confirm whether there had been any individual learning by those involved. It was not clear that there would be any better consistency of case management in prisoners who move to the Segregation Unit, nor in the way in which members were asked to attend, nor the adequacy of caremap planning. The discipline staff appeared to blame the health care staff for the incomplete health care information at reviews, but there was no indication that they accepted that the case manager and chair had responsibilities to secure the information if it was not volunteered. It remained unclear how decisions on reduction of observations would in future be fully informed in exceptional cases where vulnerable prisoners are in the Segregation Unit. Improvements in the processes and conduct of ACCT reviews may not have fully addressed the areas of concern, which create significant risks for vulnerable prisoners
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Belmarsh Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure fully informed decisions on reducing observations for vulnerable prisoners in the Segregation Unit
Wider context from the report “(1) Expert opinion has been given that the failure to routinely screen for and enquire into tobacco withdrawal as part of prison reception screening creates risks to the lives of a small number of vulnerable prisoners. Withdrawal problems may be interpreted by staff as behaviour designed to gain benefits, unless an appropriate health care assessment is conducted. Health care staff at HMP Belmarsh do not appear to be trained to conduct such screening, nor manage withdrawal, nor is it clear whose responsibility it would be.
(2) To questioning about steps that HMP had taken to reduce future risks, a governor reported a significant improvement in the conduct of ACCT reviews and pleasing spot checks. However she could not confirm whether there had been any individual learning by those involved. It was not clear that there would be any better consistency of case management in prisoners who move to the Segregation Unit, nor in the way in which members were asked to attend, nor the adequacy of caremap planning. The discipline staff appeared to blame the health care staff for the incomplete health care information at reviews, but there was no indication that they accepted that the case manager and chair had responsibilities to secure the information if it was not volunteered. It remained unclear how decisions on reduction of observations would in future be fully informed in exceptional cases where vulnerable prisoners are in the Segregation Unit . Improvements in the processes and conduct of ACCT reviews may not have fully addressed the areas of concern, which create significant risks for vulnerable prisoners
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Belmarsh Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of health care staff training to conduct tobacco-withdrawal screening
Wider context from the report “(1) Expert opinion has been given that the failure to routinely screen for and enquire into tobacco withdrawal as part of prison reception screening creates risks to the lives of a small number of vulnerable prisoners. Withdrawal problems may be interpreted by staff as behaviour designed to gain benefits, unless an appropriate health care assessment is conducted. Health care staff at HMP Belmarsh do not appear to be trained to conduct such screening , nor manage withdrawal, nor is it clear whose responsibility it would be.
(2) To questioning about steps that HMP had taken to reduce future risks, a governor reported a significant improvement in the conduct of ACCT reviews and pleasing spot checks. However she could not confirm whether there had been any individual learning by those involved. It was not clear that there would be any better consistency of case management in prisoners who move to the Segregation Unit, nor in the way in which members were asked to attend, nor the adequacy of caremap planning. The discipline staff appeared to blame the health care staff for the incomplete health care information at reviews, but there was no indication that they accepted that the case manager and chair had responsibilities to secure the information if it was not volunteered. It remained unclear how decisions on reduction of observations would in future be fully informed in exceptional cases where vulnerable prisoners are in the Segregation Unit. Improvements in the processes and conduct of ACCT reviews may not have fully addressed the areas of concern, which create significant risks for vulnerable prisoners
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Belmarsh Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely screen and enquire into tobacco withdrawal during prison reception screening
Wider context from the report “(1) Expert opinion has been given that the failure to routinely screen for and enquire into tobacco withdrawal as part of prison reception screening creates risks to the lives of a small number of vulnerable prisoners. Withdrawal problems may be interpreted by staff as behaviour designed to gain benefits, unless an appropriate health care assessment is conducted. Health care staff at HMP Belmarsh do not appear to be trained to conduct such screening, nor manage withdrawal, nor is it clear whose responsibility it would be.
(2) To questioning about steps that HMP had taken to reduce future risks, a governor reported a significant improvement in the conduct of ACCT reviews and pleasing spot checks. However she could not confirm whether there had been any individual learning by those involved. It was not clear that there would be any better consistency of case management in prisoners who move to the Segregation Unit, nor in the way in which members were asked to attend, nor the adequacy of caremap planning. The discipline staff appeared to blame the health care staff for the incomplete health care information at reviews, but there was no indication that they accepted that the case manager and chair had responsibilities to secure the information if it was not volunteered. It remained unclear how decisions on reduction of observations would in future be fully informed in exceptional cases where vulnerable prisoners are in the Segregation Unit. Improvements in the processes and conduct of ACCT reviews may not have fully addressed the areas of concern, which create significant risks for vulnerable prisoners
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Belmarsh Prison; that does not assign responsibility.
PFD Monitor interpretation Inconsistent case management for prisoners moving to the Segregation Unit
Wider context from the report “(1) Expert opinion has been given that the failure to routinely screen for and enquire into tobacco withdrawal as part of prison reception screening creates risks to the lives of a small number of vulnerable prisoners. Withdrawal problems may be interpreted by staff as behaviour designed to gain benefits, unless an appropriate health care assessment is conducted. Health care staff at HMP Belmarsh do not appear to be trained to conduct such screening, nor manage withdrawal, nor is it clear whose responsibility it would be.
(2) To questioning about steps that HMP had taken to reduce future risks, a governor reported a significant improvement in the conduct of ACCT reviews and pleasing spot checks. However she could not confirm whether there had been any individual learning by those involved. It was not clear that there would be any better consistency of case management in prisoners who move to the Segregation Unit , nor in the way in which members were asked to attend, nor the adequacy of caremap planning. The discipline staff appeared to blame the health care staff for the incomplete health care information at reviews, but there was no indication that they accepted that the case manager and chair had responsibilities to secure the information if it was not volunteered. It remained unclear how decisions on reduction of observations would in future be fully informed in exceptional cases where vulnerable prisoners are in the Segregation Unit. Improvements in the processes and conduct of ACCT reviews may not have fully addressed the areas of concern, which create significant risks for vulnerable prisoners
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Belmarsh Prison; that does not assign responsibility.
PFD Monitor interpretation Inadequate caremap planning
Wider context from the report “(1) Expert opinion has been given that the failure to routinely screen for and enquire into tobacco withdrawal as part of prison reception screening creates risks to the lives of a small number of vulnerable prisoners. Withdrawal problems may be interpreted by staff as behaviour designed to gain benefits, unless an appropriate health care assessment is conducted. Health care staff at HMP Belmarsh do not appear to be trained to conduct such screening, nor manage withdrawal, nor is it clear whose responsibility it would be.
(2) To questioning about steps that HMP had taken to reduce future risks, a governor reported a significant improvement in the conduct of ACCT reviews and pleasing spot checks. However she could not confirm whether there had been any individual learning by those involved. It was not clear that there would be any better consistency of case management in prisoners who move to the Segregation Unit, nor in the way in which members were asked to attend, nor the adequacy of caremap planning . The discipline staff appeared to blame the health care staff for the incomplete health care information at reviews, but there was no indication that they accepted that the case manager and chair had responsibilities to secure the information if it was not volunteered. It remained unclear how decisions on reduction of observations would in future be fully informed in exceptional cases where vulnerable prisoners are in the Segregation Unit. Improvements in the processes and conduct of ACCT reviews may not have fully addressed the areas of concern, which create significant risks for vulnerable prisoners
” Open source report
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations