30 May 2023 Carol Ann CLEMENTS · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 3 Inadequate falls risk assessment training during staff induction View source Failure to audit falls risk assessments for correctness View source Lack of mandatory Enhanced Supervision Levels training for new staff View source
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Carol Ann CLEMENTS · 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
Carol Ann CLEMENTS was a resident at Perry Trees Centre following surgery for a hip fracture. She was incorrectly assessed as being at medium rather than high risk of falls, fell unwitnessed, and sustained a further hip fracture. She later developed pneumonia and sepsis and died in hospital on 23 October 2022. The concerns included gaps in enhanced supervision training, induction and falls-risk assessment training for staff including agency staff, and audits that checked compliance but not correctness.
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× 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 Birmingham Community Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate falls risk assessment training during staff induction
Wider context from the report “2. Falls risk assessment training is on the essential role training programme, however, I am concerned that this area is not covered suitably on induction of staff to the centre . This leaves a gap, particularly with agency staff, and I am not satisfied that with the current processes, agency staff will be fully versed on the completion of these risk assessments .
” 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 Birmingham Community Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to audit falls risk assessments for correctness
Wider context from the report “3. I was told that since this incident, falls risk assessments are being audited for compliance . I was also told that they are not being audited for correctness . I am therefore concerned that errors, and consequently, staff training needs, would not be picked up in these audits .
” 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 Birmingham Community Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of mandatory Enhanced Supervision Levels training for new staff
Wider context from the report “1. Enhanced Supervision Levels training is not included on mandatory training programmes . Whilst some training sessions have been delivered by the trust to current staff members following this incident, I am concerned that new staff members joining will not be suitably trained in this area .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use the launched Essential Care Framework to support clinical-team self-assessment and incorporate falls-training improvements into it.
Verbatim wording from the response “The Trust has recently launched an Essential Care Framework which provides the guidance and the tools to enable clinical teams to self assess how well they meet what matters most to our patients and their relatives. This is being led by our Chief of Nursing and Therapies. The work being carried out to improve our falls risk assessments training and our enhanced supervision training will be incorporated into this framework.” Source location Response from Birmingham Community Healthcare NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit temporary-staff induction checklists through Matrons and discuss findings at inpatient quality review meetings.
Verbatim wording from the response “Each ward has a local induction checklist for temporary staff (bank and agency) who have not worked on the ward previously. The Lead Matron has reviewed the induction checklist to ensure that essential elements of Falls Risk Assessments and Falls Prevention are included. Auditing of this checklist will be the responsibility of each Matron and discussed as part of the Inpatients Quality Review meeting.” Source location Response from Birmingham Community Healthcare NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Create an action plan covering falls assessment, enhanced supervision training and falls-risk-assessment auditing.
Verbatim wording from the response “An in-depth action plan has been created around improvement to our falls assessment training, our enhanced supervision training, and how audit falls risk assessments, led by the Divisional Director of Nursing and Therapies for the Adult & Specialist Rehabilitation (A&SR) Division. This will set out both the Trust wide and divisional actions required to address your concerns, along with agreed action owners and timescales for delivery. This action plan will be submitted to the Chief of Nursing and Therapies for approval by 25 July 2023.” Source location Response from Birmingham Community Healthcare NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Classify enhanced supervision training as Essential to Role training and add it to the divisional Training Needs Analysis.
Verbatim wording from the response “The Adult & Specialist Rehabilitation Division, which covers Perry Trees Centre, already had some Enhanced Supervision training but it has now been deemed as Essential to Role and added to the Division’s Training Needs Analysis (TNA).” Source location Response from Birmingham Community Healthcare NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a quarterly falls-prevention effectiveness audit covering assessment correctness and care-plan impact.
Verbatim wording from the response “The completion of a falls risk assessment has been audited for compliance for some time as part of the Trust’s Essential Care Indicators (ECIs) audit. ECI’s take place monthly in the inpatient areas and are undertaken by the matron for each site. The discussion and learning from the round table has prompted additional measures to be introduced which will ensure that the assessment accurately reflects the risk of the patient falling and interventions required. The Matron will be undertaking spot check reviews of falls risk assessments as part of the current care rounding. In addition, the division will develop a quarterly falls prevention effectiveness audit. This will audit correctness of falls risk assessments and impact of care plans. The findings of the audits, and progress with subsequent actions, will be shared and monitored within the Inpatient Quality & Safety Committee.” Source location Response from Birmingham Community Healthcare NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver an Essential to Role training week for new starters within two months of commencing, including falls and enhanced supervision training.
Verbatim wording from the response “The Division will hold an Essential to Role training week which will follow the new starter’s Induction week. The aim is for all new starters to complete the Essential to Role training week within 2 months of commencing in post. Falls training, including Enhanced Supervision training will be incorporated into this programme. The division are also undertaking a review of how we robustly oversee this competency with all existing staff.” Source location Response from Birmingham Community Healthcare NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update temporary-staff ward induction checklists to include essential falls-risk-assessment and falls-prevention content.
Verbatim wording from the response “Each ward has a local induction checklist for temporary staff (bank and agency) who have not worked on the ward previously. The Lead Matron has reviewed the induction checklist to ensure that essential elements of Falls Risk Assessments and Falls Prevention are included. Auditing of this checklist will be the responsibility of each Matron and discussed as part of the Inpatients Quality Review meeting.” Source location Response from Birmingham Community Healthcare NHS Foundation Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct spot-check reviews of falls-risk assessments during care rounding.
Verbatim wording from the response “The completion of a falls risk assessment has been audited for compliance for some time as part of the Trust’s Essential Care Indicators (ECIs) audit. ECI’s take place monthly in the inpatient areas and are undertaken by the matron for each site. The discussion and learning from the round table has prompted additional measures to be introduced which will ensure that the assessment accurately reflects the risk of the patient falling and interventions required. The Matron will be undertaking spot check reviews of falls risk assessments as part of the current care rounding. In addition, the division will develop a quarterly falls prevention effectiveness audit. This will audit correctness of falls risk assessments and impact of care plans. The findings of the audits, and progress with subsequent actions, will be shared and monitored within the Inpatient Quality & Safety Committee.” Source location Response from Birmingham Community Healthcare NHS Foundation Trust
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21 Jan 2019 Neil Antony Black · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 4 Failure to examine injection sites and DVT sites View source Lack of joint handovers between drug detoxification and primary care nurses View source Failure to maintain an effective working relationship between IDTS and primary care nurses View source Unclear allocation of responsibility for prisoner observations View source See 1 more concern
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.
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AI-generated summary
Neil Antony Black · 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
Neil Antony Black was remanded into HMP Birmingham on 8 March 2018 after disclosing extensive alcohol and intravenous drug use and a DVT in his right leg. He became increasingly unwell in prison, was admitted to hospital on 12 March with suspected sepsis, and was diagnosed with infective endocarditis and lung abscesses before deteriorating to multi-organ failure and dying on 31 March 2018. The report identified concerns about inconsistent physical observations, inadequate interaction between prison healthcare teams, unclear responsibilities, and the lack of examination of his leg and injection sites.
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× 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 Birmingham Community Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to examine injection sites and DVT sites
Wider context from the report “3. Neil Black came into prison with a DVT in his right leg which was caused by IV drug use injecting into his groins. His groins sites and leg were not examined during his time at the prison . Consideration needs to be given to ensure there is a clear protocol for the examination of injection sites and DVT sites.
” 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 Birmingham Community Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of joint handovers between drug detoxification and primary care nurses
Wider context from the report “1. BWing is the drug detoxification wing at Birmingham prison. Prisoners undergoing drug detoxification see IDTS nurses for drug needs and primary care nurses for health care needs. Prisoners on B wing often have complex mixed needs . The evidence at the inquest confirmed there were no joint handovers despite the nurses being located very close to each other. Consideration needs to be given to joint handovers to ensure those prisoners with joint needs have a coordinated approach.
” 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 Birmingham Community Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain an effective working relationship between IDTS and primary care nurses
Wider context from the report “2. Evidence at the inquest confirmed that there was some animosity between IDTS and primary care nurses . In addition witnesses were unclear who should undertake what observations on prisoners and for what reason. Consideration needs to be given to improving the relationship and making it clearer who is responsible for what observations.
” 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 Birmingham Community Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unclear allocation of responsibility for prisoner observations
Wider context from the report “2. Evidence at the inquest confirmed that there was some animosity between IDTS and primary care nurses. In addition witnesses were unclear who should undertake what observations on prisoners and for what reason . Consideration needs to be given to improving the relationship and making it clearer who is responsible for what observations.
” Open source report
18 Dec 2018 John Anthony Delahaye · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 5 Failure to conduct a welfare check on cell unlock View source Failure to ensure healthcare attendance at ACCT reviews View source Unreliable recording of relevant past and current medical conditions View source Lack of clarity in the in possession medication risk assessment question View source Failure to use the in possession medication risk assessment View source See 2 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.
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AI-generated summary
John Anthony Delahaye · 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
John Anthony Delahaye was found dead in his cell at HMP Birmingham on 5 March 2018 after taking an insulin overdose. The report identified concerns about the clarity and use of medication risk assessments, incomplete medical records, the absence of healthcare involvement in ACCT reviews, and the failure to carry out a welfare check when his cell was unlocked.
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 Birmingham Community Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct a welfare check on cell unlock
Wider context from the report “4. On the morning of the 5th March 2018 Mr. Delahaye’s cell had been unlocked at approximately 07:50. It is likely that he was already dead at this time (and had been so for some hours) but he was not found because the prison custody officer who unlocked his cell did not look into the cell or seek any kind of acknowledgement from Mr. Delahaye. It was acknowledged by the relevant PCO and by the Safer Custody Manager that unlock ought to have involved a welfare check. The Safer Custody Manager’s evidence is that the need for a welfare check on unlock has been emphasised to senior managers and leads through a bilateral document covered at formal briefings. However, it was not clear how this is then communicated down to the individual custody officers and how they are being audited to make sure they are conducting a welfare check on unlock. The absence of a welfare check creates a risk that a prisoner in need of life saving assistance at the time of unlock is not identified.
” 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 Birmingham Community Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure healthcare attendance at ACCT reviews
Wider context from the report “3. No member of the healthcare team was present at any of Mr. Delahaye’s ACCT reviews. It was identified during the inquest that a member of either the mental health team, primary care or the drug/alcohol service ought to have been present at the first review at least. It was the evidence of a first line manager who had involvement in the ACCT that a member of the custodial team had contacted healthcare and asked them to attend but this was not documented and the healthcare team maintained they were unaware of the date of the first review. Whilst the ACCT book provides a checklist of actions to be undertaken at various times it does not include making healthcare aware of the first review. As this is a national Ministry of Justice form, HMP Birmingham can’t change it but a failure to inform healthcare of an ACCT review could result in useful knowledge or expertise not being available to the ACCT team and could put lives at risk.
” 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 Birmingham Community Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unreliable recording of relevant past and current medical conditions
Wider context from the report “2. During the inquest it emerged that the mental health nurse who assessed Mr. Delahaye on the 2nd January 2018 and the GP who assessed him for in possession medication on the 29th January 2018, had not identified from his notes all relevant past medical conditions. It emerged that whilst the System One records (a case management system used across the prison estate) has the facility to provide a summary of significant past and current medical conditions, it is not reliable at HMP Birmingham because conditions are not consistently given the correct ‘read code’ . Evidence from the NHS England clinical reviewer, ████████, was that this problem is not unique to HMP Birmingham and is found in other prison healthcare teams and requires a change of culture and practice to bring the system for read coding into line with that in the community. The absence of a reliable source for quickly identifying relevant past and current medical conditions puts lives at risk from misinformed decision making.
” 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 Birmingham Community Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity in the in possession medication risk assessment question
Wider context from the report “1. There is confusion surrounding the meaning of the following question from NHS England’s national clinical template for in possession Risk Assessments in the Secure Estate : “Have you had problems in the last 6 months with not taking, or not remembering to take your medicines as prescribed?” The Risk Assessment had not been used in the assessment for Mr. Delahaye’s in possession modification on the 29th January 2018 when it ought to have been. However, during the course of considering what the outcome would have been if the risk assessment had been undertaken, more than one clinician interpreted the question as pertaining only to consideration of incidents where medication had not been taken. It was the Coroner’s view that the question is also asking about incidents where medication may have been taken but not “as prescribed” thus encompassing an overdose (accidental or deliberate). The question is not clear and this creates a risk that the score generated may be incorrect and in possession medication may be authorised where it ought not to be, putting lives at risk.
2. During the inquest it emerged that the mental health nurse who assessed Mr. Delahaye on the 2nd January 2018 and the GP who assessed him for in possession medication on the 29th January 2018, had not identified from his notes all relevant past medical conditions. It emerged that whilst the System One records (a case management system used across the prison estate) has the facility to provide a summary of significant past and current medical conditions, it is not reliable at HMP Birmingham because conditions are not consistently given the correct ‘read code’. Evidence from the NHS England clinical reviewer, ████████, was that this problem is not unique to HMP Birmingham and is found in other prison healthcare teams and requires a change of culture and practice to bring the system for read coding into line with that in the community. The absence of a reliable source for quickly identifying relevant past and current medical conditions puts lives at risk from misinformed decision making.
3. No member of the healthcare team was present at any of Mr. Delahaye’s ACCT reviews. It was identified during the inquest that a member of either the mental health team, primary care or the drug/alcohol service ought to have been present at the first review at least. It was the evidence of a first line manager who had involvement in the ACCT that a member of the custodial team had contacted healthcare and asked them to attend but this was not documented and the healthcare team maintained they were unaware of the date of the first review. Whilst the ACCT book provides a checklist of actions to be undertaken at various times it does not include making healthcare aware of the first review. As this is a national Ministry of Justice form, HMP Birmingham can’t change it but a failure to inform healthcare of an ACCT review could result in useful knowledge or expertise not being available to the ACCT team and could put lives at risk.
4. On the morning of the 5th March 2018 Mr. Delahaye’s cell had been unlocked at approximately 07:50. It is likely that he was already dead at this time (and had been so for some hours) but he was not found because the prison custody officer who unlocked his cell did not look into the cell or seek any kind of acknowledgement from Mr. Delahaye. It was acknowledged by the relevant PCO and by the Safer Custody Manager that unlock ought to have involved a welfare check. The Safer Custody Manager’s evidence is that the need for a welfare check on unlock has been emphasised to senior managers and leads through a bilateral document covered at formal briefings. However, it was not clear how this is then communicated down to the individual custody officers and how they are being audited to make sure they are conducting a welfare check on unlock. The absence of a welfare check creates a risk that a prisoner in need of life saving assistance at the time of unlock is not identified.
” 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 Birmingham Community Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to use the in possession medication risk assessment
Wider context from the report “1. There is confusion surrounding the meaning of the following question from NHS England’s national clinical template for in possession Risk Assessments in the Secure Estate: “Have you had problems in the last 6 months with not taking, or not remembering to take your medicines as prescribed?” The Risk Assessment had not been used in the assessment for Mr. Delahaye’s in possession modification on the 29th January 2018 when it ought to have been. However, during the course of considering what the outcome would have been if the risk assessment had been undertaken, more than one clinician interpreted the question as pertaining only to consideration of incidents where medication had not been taken. It was the Coroner’s view that the question is also asking about incidents where medication may have been taken but not “as prescribed” thus encompassing an overdose (accidental or deliberate). The question is not clear and this creates a risk that the score generated may be incorrect and in possession medication may be authorised where it ought not to be, putting lives at risk.
2. During the inquest it emerged that the mental health nurse who assessed Mr. Delahaye on the 2nd January 2018 and the GP who assessed him for in possession medication on the 29th January 2018, had not identified from his notes all relevant past medical conditions. It emerged that whilst the System One records (a case management system used across the prison estate) has the facility to provide a summary of significant past and current medical conditions, it is not reliable at HMP Birmingham because conditions are not consistently given the correct ‘read code’. Evidence from the NHS England clinical reviewer, ████████, was that this problem is not unique to HMP Birmingham and is found in other prison healthcare teams and requires a change of culture and practice to bring the system for read coding into line with that in the community. The absence of a reliable source for quickly identifying relevant past and current medical conditions puts lives at risk from misinformed decision making.
3. No member of the healthcare team was present at any of Mr. Delahaye’s ACCT reviews. It was identified during the inquest that a member of either the mental health team, primary care or the drug/alcohol service ought to have been present at the first review at least. It was the evidence of a first line manager who had involvement in the ACCT that a member of the custodial team had contacted healthcare and asked them to attend but this was not documented and the healthcare team maintained they were unaware of the date of the first review. Whilst the ACCT book provides a checklist of actions to be undertaken at various times it does not include making healthcare aware of the first review. As this is a national Ministry of Justice form, HMP Birmingham can’t change it but a failure to inform healthcare of an ACCT review could result in useful knowledge or expertise not being available to the ACCT team and could put lives at risk.
4. On the morning of the 5th March 2018 Mr. Delahaye’s cell had been unlocked at approximately 07:50. It is likely that he was already dead at this time (and had been so for some hours) but he was not found because the prison custody officer who unlocked his cell did not look into the cell or seek any kind of acknowledgement from Mr. Delahaye. It was acknowledged by the relevant PCO and by the Safer Custody Manager that unlock ought to have involved a welfare check. The Safer Custody Manager’s evidence is that the need for a welfare check on unlock has been emphasised to senior managers and leads through a bilateral document covered at formal briefings. However, it was not clear how this is then communicated down to the individual custody officers and how they are being audited to make sure they are conducting a welfare check on unlock. The absence of a welfare check creates a risk that a prisoner in need of life saving assistance at the time of unlock is not identified.
” Open source report
1 Sep 2017 Mohammad Ismaeel Ashraf · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 6 Unsafe and unreliable lanyard identification of children’s food allergies View source Delays in issuing care plans for children with allergies View source Lack of a process for immediately communicating safety recommendations to affected parties View source Failure to provide issued care plans to the food provider View source Lack of care plans for all pupils who require them View source Inaccurate care plans View source See 3 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.
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AI-generated summary
Mohammad Ismaeel Ashraf · 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
Mohammad Ismaeel Ashraf, a nine-year-old boy with multiple food allergies, suffered an anaphylactic reaction at school after eating lunch and died later that day following unsuccessful resuscitation. Concerns included failures and delays in care plans, ineffective communication about allergy information, unsafe allergy-identification lanyards, and failure to administer his epipen promptly despite his deteriorating condition.
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× 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 Birmingham Community Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unsafe and unreliable lanyard identification of children’s food allergies
Wider context from the report “4. As an interim measure lanyards had been used to try and identify which food children were allergic to when buying their lunch. The Inquest heard how some lanyards were not accurate and lanyards themselves are not as safe as they may be amended or worn by a different pupil .
” 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 Birmingham Community Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in issuing care plans for children with allergies
Wider context from the report “2. That there are delays in issuing care plans . Care plans need to be issued quickly where a child has an allergy.
” 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 Birmingham Community Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a process for immediately communicating safety recommendations to affected parties
Wider context from the report “5. Immediately following this tragic event, the Local Authority procured a report to look at the safety of food delivery in the school. That report identified a number of matters requiring attention which included identifying that the lanyard system that the school had introduced as an interim measure was not safe. This recommendation and others were not communicated to the school or anyone else, to enable them to make essential changes to processes to ensure the management of children with food allergies was adequate. I am therefore concerned that the local authority has no process in place to ensure that recommendations are immediately communicated to those affected by them so that practices can be changed and processes put in place to rectify the problem.
” 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 Birmingham Community Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide issued care plans to the food provider
Wider context from the report “3. All issued care plans had not been provided to Caterlink by the school and communication between the school and Caterlink was not as effective as they could be .
” 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 Birmingham Community Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of care plans for all pupils who require them
Wider context from the report “1. That care plans are not in place for all pupils that require them . Evidence was heard at the Inquest that the deceased’s sister’s care plan is still inaccurate, despite this having been identified to the school.
” 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 Birmingham Community Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inaccurate care plans
Wider context from the report “1. That care plans are not in place for all pupils that require them. Evidence was heard at the Inquest that the deceased’s sister’s care plan is still inaccurate , despite this having been identified to the school .
” Open source report
25 Nov 2015 Dean Ronald Edmund BOLAND · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 12 Failure to monitor prisoners overnight View source Failure of prison, health and DART workers to share drug issue information adequately View source Insufficient exercise-area officer staffing for package security View source Insufficient exercise-area netting and package interception View source Failure to inform prison officers of positive drug test results View source Inadequate overnight security officer capacity for B wing View source Insufficient drug-dog coverage for screening prisoners and visitors View source Failure to check prisoners' mouths during general medicine administration View source Lack of prison officer awareness and understanding of drug issues View source Insufficient cell searching for drugs View source Lack of capability to screen incoming prisoners and visitors for concealed drugs View source Unavailability of compact drug results to DART workers 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.
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AI-generated summary
Dean Ronald Edmund BOLAND · 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
Dean Ronald Edmund Boland was found unresponsive in his cell at HMP Birmingham on 17 April 2015 and was pronounced dead shortly afterwards. Post-mortem examination confirmed multiple drugs in his system, and the inquest concluded that he died from mixed drug toxicity. The principal concerns included inadequate awareness, communication, monitoring, searching and security measures relating to drug use within the prison.
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× 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 Birmingham Community Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to monitor prisoners overnight
Wider context from the report “5. Prisoners on B wing are not viewed or monitored at all overnight unless they are on an ACCT . This gives them a considerable period of time to smoke and use drugs knowing there will be no supervision or observation from prison 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 Birmingham Community Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of prison, health and DART workers to share drug issue information adequately
Wider context from the report “2. There is a lack of multi-disciplinary approach to drug issues within the prison . The evidence heard at the inquest confirmed that prison officers, health workers and DART workers do not adequately discuss trends and general drugs issues to ensure all staff are up to date and aware of the problems . It is accepted that patient’s confidentiality needs to be maintained but it is essential to discuss trends and significant events in a multi-disciplinary way.
” 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 Birmingham Community Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient exercise-area officer staffing for package security
Wider context from the report “10. The prison should investigate whether 3 prison officer on duty in the exercise area is sufficient for 172 prisoners given the number of packages that are thrown over the walls every week .
” 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 Birmingham Community Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient exercise-area netting and package interception
Wider context from the report “9. There are several exercise areas at the prison. Only two have netting . Further consideration needs to be given to netting other areas given the number of packages being thrown over the wall and then secreted by prisoners on their person. The inquest heard that only a small proportion of packages are seized as they come over the wall .
” 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 Birmingham Community Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to inform prison officers of positive drug test results
Wider context from the report “8. Prison officers are unaware of positive drug test results and therefore unable to take any action in response .
” 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 Birmingham Community Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate overnight security officer capacity for B wing
Wider context from the report “6. The prison deploy a security officer to B wing at night (172 prisoners) .This person is unable to interact with prisoners and is only there to answer call bells . This seems inadequate given that this group of prisoners are at high risk of drug use particularly at night when there are no cell checks.
” 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 Birmingham Community Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient drug-dog coverage for screening prisoners and visitors
Wider context from the report “12. Birmingham prison has 2 drug dogs who work on a shift pattern. This means not every area in the prison can be covered as only one dog is on duty at any one time . Given that these dogs are the only current mechanism for identifying certain drugs consideration needs to be given to having more dogs so that prisoners and visitors coming into the prison will always be screened .
” 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 Birmingham Community Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to check prisoners' mouths during general medicine administration
Wider context from the report “3. General medicine administration does not involve a check of the mouth so prisoners can easily conceal tablets to sell later .
” 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 Birmingham Community Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of prison officer awareness and understanding of drug issues
Wider context from the report “1. There was a general lack of awareness and understanding of the drugs issues in the prison by prison officers . Two prison officers who worked on B wing said they were unaware of any problems with prisoners using illicit drugs including general medications . Prison officers need a comprehensive education program to understand what drugs are being used and sold and how prisoners come by those drugs.
” 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 Birmingham Community Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient cell searching for drugs
Wider context from the report “4. Cell searches only take place for a certain number of cells each month on a random basis as prescribed by NOMS, or for targeted cells when there is sufficient intelligence . Intelligence searches only take place when there is at least 2 pieces of intelligence . Given the extent of the drug problem on B wing this seems insufficient .
” 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 Birmingham Community Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of capability to screen incoming prisoners and visitors for concealed drugs
Wider context from the report “11. At present there is no ability to search or screen prisoners or visitors for drugs concealed on their person when they come into prison . Given that this is a major source of drugs coming into the prison further consideration need to be given, on a national level, as to how concealed drugs can be identified for example with the use of a full body scanner. The current scanner can only identify metal objects .
” 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 Birmingham Community Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of compact drug results to DART workers
Wider context from the report “7. DART workers are currently unable to access compact drug results as workers are unable to log onto the computer .
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations