21 Dec 2021 Saul Richard THOMAS · Prevention of Future Deaths report Worcestershire
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Concerns raised 2 Failure of inter-prison handovers to include important clinical information View source Lack of up-to-date staff training in required prison processes, including the ACCT process 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.
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AI-generated summary
Saul Richard THOMAS · 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
Saul Richard Thomas died in his cell at HMP Hewell on 19 May 2019 after being transferred there from HMP Birmingham, where he had expressed paranoid thoughts and was undergoing psychiatric assessment. The concerns included failures to open an ACCT document, communicate important mental-health information during the prison transfer, and adequately assess and manage his mental health at HMP Hewell; the inquest found that these failures probably or possibly caused or contributed to his death.
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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 Prison; that does not assign responsibility.
PFD Monitor interpretation Failure of inter-prison handovers to include important clinical information
Wider context from the report “(2) In the questionnaire which formed part of their conclusion, the jury found that the unsatisfactory handover about Mr. Thomas provided by HMP Birmingham to HMP Hewell possibly caused or contributed to his death. I heard evidence from a senior member of staff at HMP Birmingham that (a) prison staff there should have alerted their counterparts at HMP Hewell to the fact that Mr. Thomas had been undergoing psychiatric assessment within the Inpatients Unit there ; and (b) that this was still a concern which needed to be looked into. I was concerned to hear that, whilst this failing has been recognized by HMP Birmingham, no action has been taken to ensure that it will not be repeated . Until action is taken to ensure that handovers between prisons include such important information , there remains a risk of similar deaths occurring in the future.
” 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 Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of up-to-date staff training in required prison processes, including the ACCT process
Wider context from the report “(1) In the questionnaire which formed part of their conclusion, the jury found that an ACCT document should have been opened for Mr. Thomas at HMP Birmingham at some point after 11.5.19, and that a failure so to do probably caused or contributed to his death. I heard evidence from a senior member of staff at the prison that as many as a third of all staff at HMP Birmingham still do not have up-to-date training relating both to ████████ and to the ACCT process . I was also concerned to hear from one prison officer that he had had no ACCT training since 2014 . Until such training is provided to all staff working at the prison, there remains a risk of similar deaths occurring in the future;
” Open source report
23 Jun 2019 Marcus William George McGuire · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 2 Failure of managers to maintain or communicate accurate information about ACCT improvements View source Failure to provide an embedded single case manager for each ACCT 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.
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AI-generated summary
Marcus William George McGuire · 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
Marcus William George McGuire died at HMP Birmingham on 24 April 2018 after being found in his cell with a ligature around his neck. The inquest concluded that his suicide was possibly contributed to by failures to carry out a mental health assessment, respond to missed anti-psychotic medication, involve mental health services in the ACCT process, assess his risk using all relevant information, and properly manage the ACCT.
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 Prison; that does not assign responsibility.
PFD Monitor interpretation Failure of managers to maintain or communicate accurate information about ACCT improvements
Wider context from the report “1. Many of the deficiencies in Mr. McGuire’s ACCT plan, such as the absence of a properly completed care plan, the failure to involve the mental health team, failure to consider all relevant and available information and failure to carry out an effective post-closure review, were attributable to the absence of an identified case manager which resulted in different members of staff chairing his case reviews and no-one taking responsibility to follow up on action points.
2. At the time of Mr. McGuire’s death it was not uncommon for ACCTs not to have an identified case manager.
3. Evidence was given at inquest that there has been an increase in the number of trained case managers to enable all ACCTs to have a designated single case manager who will remain the case manager for the life of the ACCT so far as reasonably possible and where a change is required, there is a formal hand-over process.
4. Following completion of the evidence, the Report on an independent review of progress at HMP Birmingham by H. M. Chief Inspector of Prisons based on an inspection of the 7th to 9th May 2019 was brought to my attention. Paragraph 2.27 of the report provides:
“The quality of ACCT casework was not yet good enough. In response to our concern at the last inspection, managers had sought to deliver single case management and provide prisoners in crisis with activities. This ambition has not yet been realised. None of the eight cases we checked had a single case manager...”
5. I am also aware that in a letter dated the 11th June 2019, ████████, Head of Custodial Contracts responded to the Report on the review of progress on behalf of H. M. Prison & Probation Service. In the response it is recognised that “we need to do more to embed single case management”.
6. I am concerned that I was given the impression that single case management is embedded at HMP Birmingham: if I had been aware that it was not, I would have sought additional evidence on why, what needed to be done to “embed” single case management and how it is intended to achieve it.
7. I am concerned that the disparity between the evidence given to me and the findings upon inspection 6 weeks earlier indicates that Managers at HMP Birmingham are either not aware of or not conveying the reality of the extent to which improvements in the ACCT process have been achieved.
8. The absence of an embedded system of single case management will put lives at risk as compliance with the ACCT process cannot be assured.
” 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 Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to provide an embedded single case manager for each ACCT
Wider context from the report “1. Many of the deficiencies in Mr. McGuire’s ACCT plan, such as the absence of a properly completed care plan, the failure to involve the mental health team, failure to consider all relevant and available information and failure to carry out an effective post-closure review, were attributable to the absence of an identified case manager which resulted in different members of staff chairing his case reviews and no-one taking responsibility to follow up on action points .
2. At the time of Mr. McGuire’s death it was not uncommon for ACCTs not to have an identified case manager .
3. Evidence was given at inquest that there has been an increase in the number of trained case managers to enable all ACCTs to have a designated single case manager who will remain the case manager for the life of the ACCT so far as reasonably possible and where a change is required, there is a formal hand-over process.
4. Following completion of the evidence, the Report on an independent review of progress at HMP Birmingham by H. M. Chief Inspector of Prisons based on an inspection of the 7th to 9th May 2019 was brought to my attention. Paragraph 2.27 of the report provides:
“The quality of ACCT casework was not yet good enough. In response to our concern at the last inspection, managers had sought to deliver single case management and provide prisoners in crisis with activities. This ambition has not yet been realised. None of the eight cases we checked had a single case manager... ”
5. I am also aware that in a letter dated the 11th June 2019, ████████, Head of Custodial Contracts responded to the Report on the review of progress on behalf of H. M. Prison & Probation Service. In the response it is recognised that “we need to do more to embed single case management ”.
6. I am concerned that I was given the impression that single case management is embedded at HMP Birmingham: if I had been aware that it was not, I would have sought additional evidence on why, what needed to be done to “embed” single case management and how it is intended to achieve it.
7. I am concerned that the disparity between the evidence given to me and the findings upon inspection 6 weeks earlier indicates that Managers at HMP Birmingham are either not aware of or not conveying the reality of the extent to which improvements in the ACCT process have been achieved.
8. The absence of an embedded system of single case management will put lives at risk as compliance with the ACCT process cannot be assured.
” 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.
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 Prison; 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 Prison; 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 Prison; 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 Prison; 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 Prison; 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 Prison; 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 Prison; 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 Prison; 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 Prison; 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 Prison; 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 Prison; 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 Prison; 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
3 Sep 2014 Yohannes Kidane · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 3 Lack of sufficient staffing for effective ACCT observations View source Insufficient night staffing to enable staff comfort breaks View source Insufficient night staffing to provide healthcare and other prisoner needs 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
Yohannes Kidane · 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
Yohannes Kidane was remanded into custody at Birmingham Prison and was found in his cell with a noose around his neck after previous self-harm incidents. CPR was provided, but he was declared dead on 19 December 2013. The concerns included insufficient night staffing in the healthcare wards, compromised ACCT observations, and the impact of staff not taking breaks on prisoner care and staff wellbeing.
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 Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of sufficient staffing for effective ACCT observations
Wider context from the report “(2) I am concerned that the ability to undertake effective ACCT observations is compromised by the lack of sufficient staff .
” 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 Prison; that does not assign responsibility.
PFD Monitor interpretation Insufficient night staffing to enable staff comfort breaks
Wider context from the report “(3) When I asked how staff took breaks at night I was told staff did not take breaks during the night . I am concerned about the impact this would have on the care and wellbeing of prisoners and on the staff. Staff must need to take comfort breaks throughout the night which would add an additional burden on the already stretched staffing levels .
” 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 Prison; that does not assign responsibility.
PFD Monitor interpretation Insufficient night staffing to provide healthcare and other prisoner needs
Wider context from the report “(1) The healthcare department has 2 wards with 15 patients on each ward. The evidence presented at the inquest confirmed that at night the healthcare wards are staffed by 1 nurse per ward and 1 prison officer who is shared between both wards. Evidence confirmed there were a number of prisoners on ward 2 who required ACCT observation plus other prisoners requiring attention. At the time only 1 nurse was present as the Prison officer was on the other ward.
I am concerned the wards have insufficient staff at night to provide for all the healthcare and other needs of prisoners.
” 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