21 Mar 2024 Alan Richard Miles Davies · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 13 Failure to provide staff with clear information about food and fluid refusal duration and warning signs View source Insufficient consideration of alternative specialist placement View source Failure to provide rest breaks during prolonged night shifts View source Failure to communicate relevant clinical information before transfer View source Insufficient GP capacity to meet demand at HMP Cardiff View source Failure to provide agency staff with sufficient information for informed reception support View source Failure to accompany transfers with Caswell Clinic staff View source Failure to provide clear and understandable discharge information and assessment View source Insufficient assessment of whether needs are too complex for HMP Cardiff View source Failure of healthcare staff to challenge senior staff withdrawal from healthcare assistance View source Failure to devise and implement a clear plan for assessing capacity to refuse food or fluid View source Failure to devise and implement a clear plan for engagement with medical services and assessment of condition View source Lack of a food and fluid refusal policy View source See 10 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
Alan Richard Miles Davies · 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
Alan Richard Miles Davies was transferred to HMP Cardiff after 16 days of refusing food and was found collapsed in his cell 10 days later; he later died in hospital. The reported concerns included inadequate communication and handover of information, insufficient care planning and observation, the absence of a food and fluid refusal policy, inadequate staffing, and missed opportunities to escalate his care.
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 Cardiff Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to provide staff with clear information about food and fluid refusal duration and warning signs
Wider context from the report “(11) The Nurse, Health care assistant and Custodial manager responsible for Mr Davies on the night of his collapse were not provided with clear information regarding the duration of his fluid and food refusal or the warning signs to consider in the context of the known risk of sudden collapse
” 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 Cardiff Prison; that does not assign responsibility.
PFD Monitor interpretation Insufficient consideration of alternative specialist placement
Wider context from the report “(5) Mr Davies was transferred to HMP Cardiff with the intention that he be transferred again within a short time to HMP Parc. Insufficient consideration was given as to whether Mr Davies’ needs were better met at an alternative specialist institution .
” 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 Cardiff Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to provide rest breaks during prolonged night shifts
Wider context from the report “(10) The Nurse and Health care assistant responsible for Mr Davies on the night of his collapse were working an 11.5 hour night shift without rest breaks , which they identified as being overly fatiguing
” 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 Cardiff Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate relevant clinical information before transfer
Wider context from the report “(1) There was limited communication between the Caswell clinic and HMP Cardiff following the s 117 meeting until Mr Davies’ discharge . In particular, information that Mr Davies had commenced food refusal following the s 117 meeting and that it had not been possible to assess him physically prior to transfer was not clearly communicated to HMP Cardiff before the transfer occurred
” 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 Cardiff Prison; that does not assign responsibility.
PFD Monitor interpretation Insufficient GP capacity to meet demand at HMP Cardiff
Wider context from the report “(9) The number of GPs working in HMP Cardiff was insufficient to meet the demands upon them .
” 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 Cardiff Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to provide agency staff with sufficient information for informed reception support
Wider context from the report “(3) Mr Davies was transferred to prison without being accompanied by a member of Caswell Clinic staff. Agency staff did not have sufficient information to be able to assist prison reception staff in an informed manner
” 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 Cardiff Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to accompany transfers with Caswell Clinic staff
Wider context from the report “(3) Mr Davies was transferred to prison without being accompanied by a member of Caswell Clinic staff . Agency staff did not have sufficient information to be able to assist prison reception staff in an informed manner
” 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 Cardiff Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to provide clear and understandable discharge information and assessment
Wider context from the report “(2) Discharge information and assessment was not provided to HMP Cardiff in a clear and easily understandable format to manage the known risks associated with the transfer of Mr Davies to prison
” 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 Cardiff Prison; that does not assign responsibility.
PFD Monitor interpretation Insufficient assessment of whether needs are too complex for HMP Cardiff
Wider context from the report “(4) Insufficient consideration was given to whether Mr Davies’ needs were too complex to be met by HMP Cardiff .
” 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 Cardiff Prison; that does not assign responsibility.
PFD Monitor interpretation Failure of healthcare staff to challenge senior staff withdrawal from healthcare assistance
Wider context from the report “(12) The Health care assistant caring for Mr Davies overnight overheard more senior prison staff stating that they would not return to assist Mr Davies in healthcare , and felt unable to challenge this .
” 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 Cardiff Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to devise and implement a clear plan for assessing capacity to refuse food or fluid
Wider context from the report “(7) No clear plan for the assessment of Mr Davies’ capacity to refuse food or fluid was devised or implemented at HMP Cardiff
” 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 Cardiff Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to devise and implement a clear plan for engagement with medical services and assessment of condition
Wider context from the report “(6) No clear plan to promote Mr Davies’ engagement with prison medical services, or the assessment of his mental or physical condition was devised or implemented at HMP Cardiff
” 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 Cardiff Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of a food and fluid refusal policy
Wider context from the report “(8) No food and fluid refusal policy was in place to guide healthcare staff .
” Open source report
19 Nov 2021 Robert Ellery · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 2 Failure of the prison control room to provide specific information to the ambulance service when an ambulance is required View source Lack of a direct communication method between ambulance service call centre staff and prison staff providing basic life support View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Robert Ellery · 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
Robert Ellery was found ████████ in his prison cell on 31 October 2016. The report identified a 19-minute delay in informing the ambulance service and no direct communication method between ambulance call-centre staff and the prison staff providing basic life support. These issues delayed information sharing and impeded the provision of resuscitation guidance, giving rise to concerns about risks to other deaths.
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 Cardiff Prison; that does not assign responsibility.
PFD Monitor interpretation Failure of the prison control room to provide specific information to the ambulance service when an ambulance is required
Wider context from the report “(1) The prison control room was not able to provide the Welsh Ambulance Service with any specific information as to the reason why an ambulance was required for 19 minutes after Mr Ellery was found ████████ in his cell. This delayed the ability of the ambulance service to despatch a response . While this was not, on the evidence heard by the jury, causative of Mr Ellery’s death, it gives rise to a concern that a risk that other deaths will occur.
” 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 Cardiff Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of a direct communication method between ambulance service call centre staff and prison staff providing basic life support
Wider context from the report “(2) There was no method of communication to allow the Ambulance Service call centre staff to communicate directly with the nurse and officers who were providing basic life support to Mr Ellery. This delayed the relaying of specific information with respect to Mr Ellery’s condition by the prison to the Welsh Ambulance Service . It also impeded the ability of the ambulance service operator to provide guidance to those attempting to resuscitate Mr Ellery . This may affect the use of a defibrillator. In circumstances where not all prison staff are trained in the provision of CPR, it might also prevent the ambulance service operator providing instruction to first responders, or reduce the effectiveness of the same .
” 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 Devise a Local Operating Protocol governing direct communication between prison staff providing basic life support and the Welsh Ambulance Service.
Verbatim wording from the response “At a local level, in recognition of the concerns raised by yourself, a Local Operating Protocol has been devised. HMP Cardiff will pilot the use of a mobile phone carried by the Orderly Officer and Night Orderly Officer to enable direct communication with the Welsh Ambulance Service. This will ensure updates from the scene can be provided directly to allow the Ambulance Service call centre staff to communicate directly with the nurse and officer providing basic life support to a patient. Our Local Operating Protocol sets out the following operational objectives:” Source location 2021-0390-Response-from-HMP-Cardiff_Published
Open published response
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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 Pilot mobile phones carried by the Orderly Officer and Night Orderly Officer to enable direct communication with the Welsh Ambulance Service during emergencies.
Verbatim wording from the response “At a local level, in recognition of the concerns raised by yourself, a Local Operating Protocol has been devised. HMP Cardiff will pilot the use of a mobile phone carried by the Orderly Officer and Night Orderly Officer to enable direct communication with the Welsh Ambulance Service. This will ensure updates from the scene can be provided directly to allow the Ambulance Service call centre staff to communicate directly with the nurse and officer providing basic life support to a patient. Our Local Operating Protocol sets out the following operational objectives:” Source location 2021-0390-Response-from-HMP-Cardiff_Published
Open published response
Concerns raised 7 Absence of formal regular night checks for vulnerable prisoners View source Lack of medical or hospital treatment information in the Person Escort Record View source Insufficient efforts to find a suitable shared-cell prisoner for a first night prisoner with identified risk factors View source Inadequate handover arrangements for identifying prisoners requiring increased observations View source Failure to securely attach warning documents to the Person Escort Record View source Failure to review all available risk information in the Person Escort Record View source Reliance on prisoner interview instead of balanced assessment of all known risk factors 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
Christopher Shapley · 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
Christopher Shapley was arrested on 17 September 2013, remanded in custody, and taken to HMP Cardiff after treatment at hospital for alcohol withdrawal symptoms and fitting. He was placed alone in a cell and found hanged during morning checks on 20 September 2013. Concerns included incomplete transfer of information about his hospital treatment and self-harm risks, insufficient assessment of risk factors, inadequate efforts to arrange a shared cell, and inadequate handover and night-time observations.
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 Cardiff Prison; that does not assign responsibility.
PFD Monitor interpretation Absence of formal regular night checks for vulnerable prisoners
Wider context from the report “(4) The jury were concerned that the handover arrangements for Christopher Shapley were not adequate to identify him as a prisoner who might benefit from increased observations, and that formal regular checks should have been put in place during the night . The jury were told of new arrangements that had come into force very shortly after Christopher Shapley’s death (such as an A4 warning sheet on the cell door of every first night prisoner). The risks to vulnerable prisoners such as Christopher Shapley have been highlighted in a number of previous reports from the Cardiff Coroner to HMP Cardiff (e.g. into the death of Andrew Paul Hawkins – inquest 12th and 14th June 2012) and such arrangements should be robust and permanent.
” 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 Cardiff Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of medical or hospital treatment information in the Person Escort Record
Wider context from the report “(1) The jury found it of concern that the information that Christopher Shapley had been in Prince Charles Hospital after arrest was not known to the prison . Had it been known his condition may, they felt, have been treated more seriously and he would have been kept under greater observation. There would seem to be no reason why the PER (Person Escort Record) could not contain a section dealing with medical or hospital treatment received while in police custody prior to remand (e.g. the section at the foot of page 2 could also include a prompt for any health treatment received). This information will not only advise prison staff of the current medical circumstances of the prisoner but will also prompt them to call for any hospital discharge notes (or consult with the Force Medical Examiner) so that effective treatment can be continued.
” 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 Cardiff Prison; that does not assign responsibility.
PFD Monitor interpretation Insufficient efforts to find a suitable shared-cell prisoner for a first night prisoner with identified risk factors
Wider context from the report “(3) Despite the recommendation that he be put in a shared cell because of his alcohol withdrawal no non-smoker could be found to share with him and therefore the decision was made to put him in a cell alone. The jury found that insufficient efforts had been made to find a suitable prisoner to share with him . The jury was told that it is very rare to find a non-smoking prisoner and that it was against the regulations to ask a trusted inmate to share and desist from smoking. The risks to a first night prisoner alone in a cell with identified risk factors however go well beyond health and safety concerns and a reasoned recommendation that such a prisoner be in a shared cell should not be defeated by practicalities .
” 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 Cardiff Prison; that does not assign responsibility.
PFD Monitor interpretation Inadequate handover arrangements for identifying prisoners requiring increased observations
Wider context from the report “(4) The jury were concerned that the handover arrangements for Christopher Shapley were not adequate to identify him as a prisoner who might benefit from increased observations , and that formal regular checks should have been put in place during the night. The jury were told of new arrangements that had come into force very shortly after Christopher Shapley’s death (such as an A4 warning sheet on the cell door of every first night prisoner). The risks to vulnerable prisoners such as Christopher Shapley have been highlighted in a number of previous reports from the Cardiff Coroner to HMP Cardiff (e.g. into the death of Andrew Paul Hawkins – inquest 12th and 14th June 2012) and such arrangements should be robust and permanent.
” 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 Cardiff Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to securely attach warning documents to the Person Escort Record
Wider context from the report “(2) The PER form had a number of staple holes where extra documents had been attached. It is evident that one of these documents was a warning form prepared by a police officer enumerating the risk factors affecting Christopher Shapley. This document would have been material assistance to the prison staff, but had become detached before it reached them . A system of stapling documents to the PER is prone to human error and accidental detachment . It would appear possible for a system to be devised that ensured that any such warning form should stay securely with the PER.
” 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 Cardiff Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to review all available risk information in the Person Escort Record
Wider context from the report “(1) The Health Care Assistant who interviewed Christopher Shapley conceded that she did not look at all the pages in the PER and that she had never seen the “self-harm” form sent by Pontypridd magistrates court (and had never in fact seen any such form in all her experience in the prison). Had she seen and recognised the importance of all this information her assessment would have been broader and she would have taken into account all the risk factors rather than just alcohol withdrawal .
” 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 Cardiff Prison; that does not assign responsibility.
PFD Monitor interpretation Reliance on prisoner interview instead of balanced assessment of all known risk factors
Wider context from the report “(2) The reception prison officer was aware of the self-harm form and the alcohol withdrawal risk factor but relied heavily on the interview with Christopher Shapley in determining his care . Reliance on interview by prison staff, rather than undertaking a balanced assessment of all the known risk factors , was a feature of the evidence before the jury. The jury did however find that it was appropriate not to have raised an ACCT.
” 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