15 Oct 2025 Mr Thompson Elliott · Prevention of Future Deaths report Sunderland
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Concerns raised 4 Failure to clarify medication changes before continued administration View source Lack of clear procedures for medication management when a discharge letter cannot be located View source Failure to escalate medication uncertainty to appropriate clinical advisers View source Failure to accurately record replacement medication on the electronic medication record View source See 1 more concern
Responses linked to these concerns
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AI-generated summary
Mr Thompson Elliott · 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
Thompson Elliott, a care home resident, was admitted to hospital with chest pains and discharged with changed opioid medication. Because the discharge letter could not be located, both old and new opioids were administered, resulting in an overdose; he later contracted influenza A in hospital and died after respiratory failure. The principal concerns were unclear procedures, inadequate medication recording and administration, and inconsistent staff decisions when discharge information was unavailable.
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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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure to clarify medication changes before continued administration
Wider context from the report “The evidence has revealed significant concerns with regard to the recording and administration of medication, when patients return to the care home, and a discharge letter cannot be located following a period in hospital.
I am concerned that the evidence was that if a patient returned to the care home with new medication prescribed whilst in hospital to replace previously prescribed medication, and the patient’s discharge letter could not be immediately located, there would be uncertainty amongst staff as to the correct procedure to follow in such circumstances.
Medication that had been stopped whilst in hospital due to its impact upon the patient’s kidneys continued to be administered on 18th and 19th December 2024, before it could be clarified with either the hospital or GP which was the correct medication . The new medication was not administered on either of those days.
The evidence revealed that the new medication was not immediately recorded onto the patient’s electronic medication record (EMAR) and held in a cupboard pending clarification. Despite no clarification and following a 24-hour delay, it was then incorrectly added to the record as new and additional medication - not replacement medication.
The medication had been changed to oxycodone due to the impact oramorph was having upon the patient’s kidneys. Due to the administration error in recording oxycodone as new and therefore additional medication, the patient was then given both oramorph and the new oxycodone medication on the morning and afternoon of 20th December 2024 which was 2 days following his discharge. This resulted in an opioid overdose.
I am concerned that the evidence was such that it was not possible to determine exactly what efforts, if any, were made by staff to clarify the medication position with the hospital on either 18th, 19th or 20th December 2024 but medication continued to be administered . On 21st December 2024 a team leader was able to speak to the hospital and despite being advised that if there was no discharge letter to take all medications and clarify the position with the GP, a decision was made to only administer the old medication of oramorph and there no attempts to contact the GP. There were no attempts to contact 111 or Recovery at Home for advice.
I am concerned that the evidence revealed that there was no policy or guidance document setting out the procedures, which staff must follow in such circumstances, which created confusion and inconsistent decision making resulting in a medication overdose and continued use of a medication that had been stopped in hospital due to the harm it was causing to the patient’s kidneys.
The evidence raises a further concern that the procedure still remains unclear despite internal reviews following the death.
I shall be glad to be told of any learning arising from this death and timescales and results of your review.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care UK; that does not assign responsibility.
PFD Monitor interpretation Lack of clear procedures for medication management when a discharge letter cannot be located
Wider context from the report “The evidence has revealed significant concerns with regard to the recording and administration of medication, when patients return to the care home, and a discharge letter cannot be located following a period in hospital.
I am concerned that the evidence was that if a patient returned to the care home with new medication prescribed whilst in hospital to replace previously prescribed medication, and the patient’s discharge letter could not be immediately located, there would be uncertainty amongst staff as to the correct procedure to follow in such circumstances .
Medication that had been stopped whilst in hospital due to its impact upon the patient’s kidneys continued to be administered on 18th and 19th December 2024, before it could be clarified with either the hospital or GP which was the correct medication. The new medication was not administered on either of those days.
The evidence revealed that the new medication was not immediately recorded onto the patient’s electronic medication record (EMAR) and held in a cupboard pending clarification. Despite no clarification and following a 24-hour delay, it was then incorrectly added to the record as new and additional medication - not replacement medication.
The medication had been changed to oxycodone due to the impact oramorph was having upon the patient’s kidneys. Due to the administration error in recording oxycodone as new and therefore additional medication, the patient was then given both oramorph and the new oxycodone medication on the morning and afternoon of 20th December 2024 which was 2 days following his discharge. This resulted in an opioid overdose.
I am concerned that the evidence was such that it was not possible to determine exactly what efforts, if any, were made by staff to clarify the medication position with the hospital on either 18th, 19th or 20th December 2024 but medication continued to be administered. On 21st December 2024 a team leader was able to speak to the hospital and despite being advised that if there was no discharge letter to take all medications and clarify the position with the GP, a decision was made to only administer the old medication of oramorph and there no attempts to contact the GP. There were no attempts to contact 111 or Recovery at Home for advice.
I am concerned that the evidence revealed that there was no policy or guidance document setting out the procedures, which staff must follow in such circumstances , which created confusion and inconsistent decision making resulting in a medication overdose and continued use of a medication that had been stopped in hospital due to the harm it was causing to the patient’s kidneys.
The evidence raises a further concern that the procedure still remains unclear despite internal reviews following the death.
I shall be glad to be told of any learning arising from this death and timescales and results of your review.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate medication uncertainty to appropriate clinical advisers
Wider context from the report “The evidence has revealed significant concerns with regard to the recording and administration of medication, when patients return to the care home, and a discharge letter cannot be located following a period in hospital.
I am concerned that the evidence was that if a patient returned to the care home with new medication prescribed whilst in hospital to replace previously prescribed medication, and the patient’s discharge letter could not be immediately located, there would be uncertainty amongst staff as to the correct procedure to follow in such circumstances.
Medication that had been stopped whilst in hospital due to its impact upon the patient’s kidneys continued to be administered on 18th and 19th December 2024, before it could be clarified with either the hospital or GP which was the correct medication. The new medication was not administered on either of those days.
The evidence revealed that the new medication was not immediately recorded onto the patient’s electronic medication record (EMAR) and held in a cupboard pending clarification. Despite no clarification and following a 24-hour delay, it was then incorrectly added to the record as new and additional medication - not replacement medication.
The medication had been changed to oxycodone due to the impact oramorph was having upon the patient’s kidneys. Due to the administration error in recording oxycodone as new and therefore additional medication, the patient was then given both oramorph and the new oxycodone medication on the morning and afternoon of 20th December 2024 which was 2 days following his discharge. This resulted in an opioid overdose.
I am concerned that the evidence was such that it was not possible to determine exactly what efforts, if any, were made by staff to clarify the medication position with the hospital on either 18th, 19th or 20th December 2024 but medication continued to be administered. On 21st December 2024 a team leader was able to speak to the hospital and despite being advised that if there was no discharge letter to take all medications and clarify the position with the GP, a decision was made to only administer the old medication of oramorph and there no attempts to contact the GP . There were no attempts to contact 111 or Recovery at Home for advice.
I am concerned that the evidence revealed that there was no policy or guidance document setting out the procedures, which staff must follow in such circumstances, which created confusion and inconsistent decision making resulting in a medication overdose and continued use of a medication that had been stopped in hospital due to the harm it was causing to the patient’s kidneys.
The evidence raises a further concern that the procedure still remains unclear despite internal reviews following the death.
I shall be glad to be told of any learning arising from this death and timescales and results of your review.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure to accurately record replacement medication on the electronic medication record
Wider context from the report “The evidence has revealed significant concerns with regard to the recording and administration of medication, when patients return to the care home, and a discharge letter cannot be located following a period in hospital.
I am concerned that the evidence was that if a patient returned to the care home with new medication prescribed whilst in hospital to replace previously prescribed medication, and the patient’s discharge letter could not be immediately located, there would be uncertainty amongst staff as to the correct procedure to follow in such circumstances.
Medication that had been stopped whilst in hospital due to its impact upon the patient’s kidneys continued to be administered on 18th and 19th December 2024, before it could be clarified with either the hospital or GP which was the correct medication. The new medication was not administered on either of those days.
The evidence revealed that the new medication was not immediately recorded onto the patient’s electronic medication record (EMAR) and held in a cupboard pending clarification. Despite no clarification and following a 24-hour delay, it was then incorrectly added to the record as new and additional medication - not replacement medication .
The medication had been changed to oxycodone due to the impact oramorph was having upon the patient’s kidneys. Due to the administration error in recording oxycodone as new and therefore additional medication , the patient was then given both oramorph and the new oxycodone medication on the morning and afternoon of 20th December 2024 which was 2 days following his discharge. This resulted in an opioid overdose.
I am concerned that the evidence was such that it was not possible to determine exactly what efforts, if any, were made by staff to clarify the medication position with the hospital on either 18th, 19th or 20th December 2024 but medication continued to be administered. On 21st December 2024 a team leader was able to speak to the hospital and despite being advised that if there was no discharge letter to take all medications and clarify the position with the GP, a decision was made to only administer the old medication of oramorph and there no attempts to contact the GP. There were no attempts to contact 111 or Recovery at Home for advice.
I am concerned that the evidence revealed that there was no policy or guidance document setting out the procedures, which staff must follow in such circumstances, which created confusion and inconsistent decision making resulting in a medication overdose and continued use of a medication that had been stopped in hospital due to the harm it was causing to the patient’s kidneys.
The evidence raises a further concern that the procedure still remains unclear despite internal reviews following the death.
I shall be glad to be told of any learning arising from this death and timescales and results of your review.
” 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 Train staff to escalate hospital-return medication queries, obtain same-day clarification and document communications, actions and handovers.
Verbatim wording from the response “Discussion and further refresher training with all relevant staff has emphasized the need to ensure home management is informed immediately of any concerns regarding residents returning from hospital and that checks are undertaken with the hospital. The training has reinforced that if the hospital cannot be reached for an answer, colleagues should check with the GP and failing that contact the 111 service.” Source location Response from Care UK
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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 Review hospital discharges monthly for compliance with discharge processes and completion of medication updates and follow-up actions.
Verbatim wording from the response “There is now a monthly review of hospital discharges checking compliance with the relevant processes outlined above; medication is promptly updated and any required follow-up actions completed.” Source location Response from Care UK
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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 Reinforce hospital-return, discharge and medication-management policies through mandatory read-and-sign confirmation and refresher training.
Verbatim wording from the response “The care home leadership has reinforced Care UK's 'Admissions and Discharge Policy' (enclosure 2) and the 'How to Guide - Supporting a Resident Returning from Hospital' (enclosure 3) as well as the 'Medications Management Policy' (enclosure 4). These documents provide clear guidance to staff as to what to do in circumstances where a resident arrives and/or returns to the care home from hospital and there is insufficient/absent information regarding their discharge and attendant medications. All staff have completed a mandatory "read and sign" process to confirm that they have read and understood these documents, all of which have been discussed with staff as part of further refresher training sessions undertaken.” Source location Response from Care UK
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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 Introduce and disseminate a visual flow chart guiding staff through medication checks when residents return from hospital without discharge documentation.
Verbatim wording from the response “To remind staff, a visual flow chart has been introduced at the care home to provide clear, step-by-step guidance for staff involved in supporting residents returning from hospital where there is no accompanying discharge letter to support changes in medication. A copy of this flow chart, which has been shared and discussed with staff to embed awareness of it, accompanies this letter (enclosure 1). This flowchart is laminated and attached to the medication keys as an immediate prompt to staff. Additionally, there are copies of this flow chart in poster format on the wall of the care home's treatment room and there is a further copy contained within a dedicated discharge file held in the Deputy Manager's office. This dedicated file has been brought in following this case and contains the flow chart prompt and copies of Care UK's relevant up-to-date policies to which I refer below.” Source location Response from Care UK
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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 Continue working with hospital Trusted Assessors to streamline secure, prompt sharing of discharge information and support safe transitions of care.
Verbatim wording from the response “The care home has continued to work closely with the Trusted Assessor team at the hospital which discharged Mr Elliott to try to streamline communication/interaction in relation to discharges. The aim is to ensure all documents are securely and promptly shared including via NHS email if possible to support timely and safe transitions of care from hospital to the care home. This work is ongoing but the care home and its hospital partners share a commitment to best practice to achieve these aims. As noted above, the Home Manager has held meetings with the local hospital's Trusted Assessors to discuss the care home's discharge policies to ensure agreement and buy in to the process.” Source location Response from Care UK
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 Deliver additional medication education, reflection workbooks, medication-policy confirmation and renewed medication and electronic-record training for staff.
Verbatim wording from the response “The care home has run extra medication training sessions to raise knowledge of and test understanding of drugs in use at the care home including why they are prescribed, the effects/side effects, brand names and generic names. The refresher training also included how the online British National Formulary should be used. To begin with this additional training focused only on the pain relief medication in Mr Elliott's case but, due to its success, has since focused on other drugs commonly in use at the care home.” Source location Response from Care UK
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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 Discuss imminent and new hospital discharges at daily and weekly clinical meetings so required information and follow-up actions are identified.
Verbatim wording from the response “The Home Manager and/or Deputy will ensure that any imminent or new discharges to the care home are discussed at the daily 10@10 meetings and weekly clinical review meetings to ensure staff are aware of the discharges, the relevant information is obtained and any matters requiring follow-up are actioned. In addition, it is also important to note that there is always a member of the management team available (seven days a week) and so at any time the discharge process is taking place, there are senior staff available to help deal with/advise on any issues arising with the discharge.” Source location Response from Care UK
Open published response
7 Aug 2025 Marion Jones · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Failure to ensure bed rails are in place when required View source Failure to conduct timely bed-rail assessments View source Lack of nursing staff knowledge about bed-rail assessment and requirements 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
Marion Jones · 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
Marion Jones, who had stage 4 lung cancer and required assistance with movement, fell from an unrailed bed at Riverside care home on 23 March 2025, sustaining a head injury. The principal concerns were that no bed-rail assessment was recorded or carried out despite family concerns, and that nursing staff lacked a clear understanding of the required assessment process and timing.
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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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure bed rails are in place when required
Wider context from the report “1. No pre-admission assessment for bed rails was recorded by the staff member responsible from Riverside, and this does not appear to have taken place. This is in circumstances where bed rails were already in place at Willow Wood and where there were obvious and recorded difficulties with regard to movement in and about bed, in addition to physical activity more generally. Given the circumstances, a pre-admission assessment for bed rails should have taken place and / or been recorded.
2. The inquest heard that family members raised their concerns on admission of Marion Jones to Riverside when they saw there were no bed rails. They were assured that an assessment would take place. This did not happen: it should have done.
3. The manager of the care home agreed that in all the circumstances, including the concerns of the family, such an assessment should have taken place.
4. A registered general nurse involved in care for Marion Jones, and who found her after she had fallen, gave evidence that an assessment for bed rails should have taken place 48-72 hours after admission. The manager of the care home gave evidence that such an assessment should take place as promptly as possible, and that 48-72 hours did not meet this requirement. There is did not appear to appreciate the time within which such an assessment should be conducted.
5. Another registered general nurse involved in the care of Marion Jones gave evidence that she was not sure in what period of time an assessment for bed rails should take place.
6. Therefore, nursing staff responsible for the care of Marion Jones did not know what the appropriate approach was to assessment for bed rails. The awareness of nursing staff at Riverside with regard to assessment for and / or the requirement for bed rails was not apparent
7. The inquest heard that there have been previous incidents where bed rails have not been in place.
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct timely bed-rail assessments
Wider context from the report “1. No pre-admission assessment for bed rails was recorded by the staff member responsible from Riverside, and this does not appear to have taken place. This is in circumstances where bed rails were already in place at Willow Wood and where there were obvious and recorded difficulties with regard to movement in and about bed, in addition to physical activity more generally. Given the circumstances, a pre-admission assessment for bed rails should have taken place and / or been recorded.
2. The inquest heard that family members raised their concerns on admission of Marion Jones to Riverside when they saw there were no bed rails. They were assured that an assessment would take place. This did not happen: it should have done.
3. The manager of the care home agreed that in all the circumstances, including the concerns of the family, such an assessment should have taken place.
4. A registered general nurse involved in care for Marion Jones, and who found her after she had fallen, gave evidence that an assessment for bed rails should have taken place 48-72 hours after admission. The manager of the care home gave evidence that such an assessment should take place as promptly as possible, and that 48-72 hours did not meet this requirement. There is did not appear to appreciate the time within which such an assessment should be conducted.
5. Another registered general nurse involved in the care of Marion Jones gave evidence that she was not sure in what period of time an assessment for bed rails should take place.
6. Therefore, nursing staff responsible for the care of Marion Jones did not know what the appropriate approach was to assessment for bed rails. The awareness of nursing staff at Riverside with regard to assessment for and / or the requirement for bed rails was not apparent
7. The inquest heard that there have been previous incidents where bed rails have not been in place.
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Lack of nursing staff knowledge about bed-rail assessment and requirements
Wider context from the report “1. No pre-admission assessment for bed rails was recorded by the staff member responsible from Riverside, and this does not appear to have taken place. This is in circumstances where bed rails were already in place at Willow Wood and where there were obvious and recorded difficulties with regard to movement in and about bed, in addition to physical activity more generally. Given the circumstances, a pre-admission assessment for bed rails should have taken place and / or been recorded.
2. The inquest heard that family members raised their concerns on admission of Marion Jones to Riverside when they saw there were no bed rails. They were assured that an assessment would take place. This did not happen: it should have done.
3. The manager of the care home agreed that in all the circumstances, including the concerns of the family, such an assessment should have taken place.
4. A registered general nurse involved in care for Marion Jones, and who found her after she had fallen, gave evidence that an assessment for bed rails should have taken place 48-72 hours after admission. The manager of the care home gave evidence that such an assessment should take place as promptly as possible, and that 48-72 hours did not meet this requirement. There is did not appear to appreciate the time within which such an assessment should be conducted.
5. Another registered general nurse involved in the care of Marion Jones gave evidence that she was not sure in what period of time an assessment for bed rails should take place.
6. Therefore, nursing staff responsible for the care of Marion Jones did not know what the appropriate approach was to assessment for bed rails. The awareness of nursing staff at Riverside with regard to assessment for and / or the requirement for bed rails was not apparent
7. The inquest heard that there have been previous incidents where bed rails have not been in place.
” 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 Launch a bed-rails e-learning module covering policies and procedures for colleagues conducting bed-rail assessments.
Verbatim wording from the response “As previously outlined, we have made changes to our pre-admission pro-forma and admission checklist that will ensure that colleagues consider bed rails assessments before and after admission. In addition to these changes, we are launching a Bed Rails eLearning module which will improve the knowledge of colleagues assessing residents in relation to our policies and procedures regarding bed rails assessments. This eLearning module will be live on our e-learning platform from 13 October 2025.” Source location Response from Care UK
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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 Add an admission-checklist completeness question to monthly Go Audits to enable management auditing against required completion timeframes.
Verbatim wording from the response “Also, we have amended our documentation on our “Go Audits” tool. These are audits completed on a monthly basis by our Deputy Home Managers. They look at the individual assessments that form part of a resident’s care plan, for example: MUST Assessment, MFRA Assessment, Choking Risk Assessment, etc. The Audit ensures that all necessary parts of a care plan have been completed, all necessary information has been included, and the information is up-to-date. We have now added an additional question that covers the completeness of the Admission Checklist within the required timeframes. These amendments will go live this month and will allow management to audit compliance with the implemented changes.” Source location Response from Care UK
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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 Revise the admission checklist to specify timely post-admission assessment of bed rails and other fall-prevention equipment, with clearer completion prompts and reasons for omissions.
Verbatim wording from the response “B. Admission check-list form” Source location Response from Care UK
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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 Update the pre-admission assessment proforma to prompt bed-rail assessment, record relevant falls and equipment history, and require Home Manager completion checks.
Verbatim wording from the response “It is Care UK policy where residents are assessed or present as being at risk of falling out of bed, the use of bed rails should be considered. In Marion’s case, the pre-admission assessment did not identify a risk of falling out of bed that would have triggered the bed rails assessment. However, Marion had bed rails in her previous placement and upon admission her family raised concerns regarding bed rails. In those circumstances, Danielle agreed that a bed rail assessment should have taken place. In order to prevent this happening again in the future, we have made the following changes outlined below:” Source location Response from Care UK
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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 Publish the updated pre-admission assessment and admission checklist on the intranet and circulate them internally with a link from 7 October 2025.
Verbatim wording from the response “The updated pre-admission assessment and admission checklist will be live on our intranet “mycareuk” from 7 October 2025 and an email from our internal communications platform “iCommunicate” will be circulated with a link to these forms on the same day.” Source location Response from Care UK
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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 Update Care and Clinical Meeting Notes to require checks against completed risk assessments and timely completion of admission checklists.
Verbatim wording from the response “Finally, we have updated our Care & Clinical Meeting Notes form to include that checks should be made as per completed risk assessments, and that the admission checklist should be fully completed within the required timeframes.” Source location Response from Care UK
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Previous incidents involved crash mats or low-rise beds; there were no reported falls without bed rails or alternative protective measures.
Verbatim wording from the response “Your final concern was regarding evidence given during the inquest that there have been previous incidents where bed rails have not been in place. I discussed this concern with the Home Manager and the Regional Director for Riverside care home. Danielle explained that during the inquest she gave evidence that previous incidents had occurred where bed rails were not in place. However, she explained to me that she was referring to incidents where residents had rolled out of bed without bed rails in place, but a low-rise bed with a crash mat was in place or a resident prevent injury. She has reassured me that she was not referring to any previous incident where a resident with no bed rails had fallen out of bed with no fall out (crash) mat.” Source location Response from Care UK
Open published response
6 Jun 2023 Jennifer Evelyn RACKLEY · Prevention of Future Deaths report Berkshire
View report summary
Concerns raised 4 Failure to document investigations of incidents View source Failure to identify care staff involved in incidents View source Insufficient sensor mat provision for a high-falls-risk resident View source Failure to position a high-falls-risk resident’s bed appropriately 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
Jennifer Evelyn RACKLEY · 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
Jennifer Evelyn Rackley died at Wexham Park Hospital on 15 January 2022 after a fall at her nursing home on 17 December 2021. Concerns included that her bed may have been in the centre of the room with only one sensor mat despite her high falls risk, and that the care home's reported investigation had no written record and could not identify the carers involved.
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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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure to document investigations of incidents
Wider context from the report “(2) Evidence was given that an investigation was carried out – despite no written document / record of this being made - and the manager being unable even to name the care staff involved in the incident.
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure to identify care staff involved in incidents
Wider context from the report “(2) Evidence was given that an investigation was carried out – despite no written document / record of this being made - and the manager being unable even to name the care staff involved in the incident .
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Insufficient sensor mat provision for a high-falls-risk resident
Wider context from the report “(1) It seems likely that Jennifer’s bed was in the centre of the room, with one sensor mat only, despite a high falls 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure to position a high-falls-risk resident’s bed appropriately
Wider context from the report “(1) It seems likely that Jennifer’s bed was in the centre of the room , with one sensor mat only, despite a high falls risk.
” Open source report
20 Mar 2020 John Francis GREGORY · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 9 Failure to escalate and respond to prolonged inadequate fluid intake View source Failure to provide bedtime arrangements based on patients’ needs rather than nursing routine View source Failure to secure patients safely in wheelchairs View source Failure to provide adequate clothing for patients unable to dress themselves View source Failure to encourage patients to drink or eat when intake is inadequate View source Failure to provide consistent toileting and continence care View source Failure to consistently encourage sufficient drinking and eating View source Failure to monitor patients in communal areas View source Inaccurate recording of patients’ fluid intake View source See 6 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 Francis GREGORY · 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 Francis Gregory died after developing acute kidney injury associated with low oral fluid intake, in the context of Alzheimer’s disease and old age. Concerns included inadequate encouragement and monitoring of drinking in hospital rehabilitation and residential care, inaccurate fluid-intake records, and failures to escalate or respond to his deterioration at Muriel Street Resource Centre.
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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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate and respond to prolonged inadequate fluid intake
Wider context from the report “4. Mr Gregory’s oral fluid intake was also too low at Muriel Street, a nursing home specialising in the care of those with dementia.
On his last day at the home, Mr Gregory was described in the nursing notes as drinking, but his chart showed that he had drunk nothing since a cup of tea at 8.20am . The ambulance was called at 5.17pm.
The fact that he had not drunk the whole day was not escalated to a senior member of staff and there was no evidence that any steps had been taken to deal with this .
His fluid intake chart recorded him as repeatedly declining drinks, even at a time after he had lost consciousness and an ambulance had already been called for him.
This demonstrates that the chart was inaccurate. It raises the possibility that the chart was inaccurate in other ways. It raises the possibility that when Mr Gregory was described as declining drinks, in fact staff were not taking any steps to encourage him to drink, or to eat.
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure to provide bedtime arrangements based on patients’ needs rather than nursing routine
Wider context from the report “1. Whilst the sister in charge of Evergreen plainly led from the front and expected the highest standards, these were not always maintained by every member of staff.
On one occasion, a member of staff refused Mr Gregory’s family assistance to take him to the toilet; on more than one occasion his family found him in wet bedclothes; and he was put to bed at 7.30pm to fit in with nursing routine .
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure to secure patients safely in wheelchairs
Wider context from the report “3. On the day he was readmitted to hospital from Muriel Street, Mr Gregory’s family found him slumped unconscious in a public area of the home, a fact unnoticed by any member of staff.
He was not properly strapped in to a wheelchair, slipping down because his feet were not on the foot rests . He was cold and inadequately dressed, with his shirt undone and not wearing socks. By then Mr Gregory was not capable of dressing himself.
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure to provide adequate clothing for patients unable to dress themselves
Wider context from the report “3. On the day he was readmitted to hospital from Muriel Street, Mr Gregory’s family found him slumped unconscious in a public area of the home, a fact unnoticed by any member of staff.
He was not properly strapped in to a wheelchair, slipping down because his feet were not on the foot rests. He was cold and inadequately dressed, with his shirt undone and not wearing socks . By then Mr Gregory was not capable of dressing himself .
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure to encourage patients to drink or eat when intake is inadequate
Wider context from the report “4. Mr Gregory’s oral fluid intake was also too low at Muriel Street, a nursing home specialising in the care of those with dementia.
On his last day at the home, Mr Gregory was described in the nursing notes as drinking, but his chart showed that he had drunk nothing since a cup of tea at 8.20am. The ambulance was called at 5.17pm.
The fact that he had not drunk the whole day was not escalated to a senior member of staff and there was no evidence that any steps had been taken to deal with this.
His fluid intake chart recorded him as repeatedly declining drinks, even at a time after he had lost consciousness and an ambulance had already been called for him.
This demonstrates that the chart was inaccurate. It raises the possibility that the chart was inaccurate in other ways. It raises the possibility that when Mr Gregory was described as declining drinks, in fact staff were not taking any steps to encourage him to drink, or to eat .
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure to provide consistent toileting and continence care
Wider context from the report “1. Whilst the sister in charge of Evergreen plainly led from the front and expected the highest standards, these were not always maintained by every member of staff .
On one occasion, a member of staff refused Mr Gregory’s family assistance to take him to the toilet ; on more than one occasion his family found him in wet bedclothes ; and he was put to bed at 7.30pm to fit in with nursing routine.
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure to consistently encourage sufficient drinking and eating
Wider context from the report “2. His oral fluid intake was considered by Evergreen Ward, and steps were taken to address this, but the intake recorded on his charts demonstrate that it remained too low .
Maintaining sufficient fluid intake was a challenge, but there is the possibility that not every member of staff encouraged him to drink and eat in the way the sister in charge did.
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure to monitor patients in communal areas
Wider context from the report “3. On the day he was readmitted to hospital from Muriel Street, Mr Gregory’s family found him slumped unconscious in a public area of the home, a fact unnoticed by any member of staff .
He was not properly strapped in to a wheelchair, slipping down because his feet were not on the foot rests. He was cold and inadequately dressed, with his shirt undone and not wearing socks. By then Mr Gregory was not capable of dressing himself.
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Inaccurate recording of patients’ fluid intake
Wider context from the report “4. Mr Gregory’s oral fluid intake was also too low at Muriel Street, a nursing home specialising in the care of those with dementia.
On his last day at the home, Mr Gregory was described in the nursing notes as drinking, but his chart showed that he had drunk nothing since a cup of tea at 8.20am. The ambulance was called at 5.17pm.
The fact that he had not drunk the whole day was not escalated to a senior member of staff and there was no evidence that any steps had been taken to deal with this.
His fluid intake chart recorded him as repeatedly declining drinks, even at a time after he had lost consciousness and an ambulance had already been called for him .
This demonstrates that the chart was inaccurate . It raises the possibility that the chart was inaccurate in other ways. It raises the possibility that when Mr Gregory was described as declining drinks, in fact staff were not taking any steps to encourage him to drink, or to eat.
” Open source report
30 Oct 2019 Robert Thomas GINN · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 7 Failure to coach non-clinical staff to improve chest compressions View source Failure to check breathing during resuscitation View source Failure of a nurse to administer chest compressions View source Failure to maintain oxygenation throughout nurse-led resuscitation View source Failure to confirm absent breathing using an adequate assessment View source Failure to provide consistently effective chest compressions View source Incorrect application of defibrillator pads View source See 4 more concerns
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 Thomas GINN · 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 Thomas Ginn hanged himself in his cell at HM Prison Pentonville and was discovered at around 1.05am on 29 November 2018. Concerns were raised about the quality of the nurse-led resuscitation attempt, including failure to check breathing, inadequate oxygenation, variable chest compressions, lack of coaching, and incorrectly applied defibrillator pads.
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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure to coach non-clinical staff to improve chest compressions
Wider context from the report “7. No attempt was made by either of the nurses to coach the prison officer to improve the quality of chest compressions .
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure to check breathing during resuscitation
Wider context from the report “2. Throughout the resuscitation attempt captured on BWC, no staff member checked Mr Ginn’s breathing .
It is possible that the breathing was checked before the commencement of the bodycam footage, and indeed one of the prison officers said he checked it at the outset, but the footage ran for nearly eleven minutes before the London Ambulance Service arrived and took over, and it was not checked in that time .
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure of a nurse to administer chest compressions
Wider context from the report “8. One of the nurses (Hotel 7) did not administer chest compressions at all . She did not give evidence at inquest and so the reason for this is unclear.
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain oxygenation throughout nurse-led resuscitation
Wider context from the report “4. After the first two minutes of footage, the oxygen mask that had been in place was taken off and no further efforts were made to oxygenate Mr Ginn .
5. Given that Mr Ginn’s heart had stopped beating, he must have stopped breathing as well. A full, effective, nurse led resuscitation attempt should have included an attempt to oxygenate throughout .
Hotel 12 said that she did not do this because Mr Ginn’s jaw was too stiff to insert an airway, but the LAS did so without any difficulty. And if he had been cold and stiff when they arrived, the LAS paramedics would not have commenced resuscitation.
In any event, an oxygen mask can be applied even if there is stiffness (as it was here, but then it was removed two minutes into the resuscitation and nearly nine minutes before LAS took over).
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure to confirm absent breathing using an adequate assessment
Wider context from the report “3. At inquest, one of the nurses said that she looked at Mr Ginn’s chest at the outset, but she did not put her cheek to his mouth to listen and feel for breath in order to confirm he was not breathing .
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure to provide consistently effective chest compressions
Wider context from the report “6. Chest compressions given by different members of staff were variable and some, including those of one of the nurses, were sub optimal .
At one point, chest compressions were given by a staff member sandwiched between Mr Ginn and the wall, where there was not enough space to be effective .
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Incorrect application of defibrillator pads
Wider context from the report “9. The defibrillator pads were incorrectly applied by the nursing team , rendering the defibrillator reading unreliable .
” 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 Require annual Immediate Life Support training for employed resuscitation staff and monitor compliance through monthly dashboards and the Resuscitation Committee.
Verbatim wording from the response “Our policy for the standards of training for employed staff within our Health in Justice service who respond to resuscitation is Immediate Life Support (ILS) training, provided by Resuscitation Council accredited trainers. Although the requirement from the Resuscitation Council is that attendee’s repeat this on a 3 yearly cycle, we mandate that all Care UK employed staff complete this annually. Assurance around the compliance of this training is monitored via monthly performance dashboards and reported to Care UK’s Resuscitation Committee.” Source location Response from Care UK
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 Film selected scenario-based resuscitation exercises for use in in-house training and induction.
Verbatim wording from the response “Going forwards, we will contract with our ILS training provider to deliver additional training sessions, including some prison scenario based training. These will be in addition to the annual re-certification sessions. We anticipate that this will be rolled out across our sites nationally over 2020. In addition our intention is to film some of these scenario-based training exercises for use at in-house training events and induction.” Source location Response from Care UK
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 Contract for additional prison-scenario Immediate Life Support training sessions beyond annual recertification across Care UK sites.
Verbatim wording from the response “Going forwards, we will contract with our ILS training provider to deliver additional training sessions, including some prison scenario based training. These will be in addition to the annual re-certification sessions. We anticipate that this will be rolled out across our sites nationally over 2020. In addition our intention is to film some of these scenario-based training exercises for use at in-house training events and induction.” Source location Response from Care UK
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 Request CCTV or body-worn-camera footage after on-site custody deaths involving resuscitation and review it through immediate and internal learning reviews.
Verbatim wording from the response “Following a death in custody where resuscitation has taken place on site, a request is made to the prison for the opportunity to view or receive a copy of any CCTV or body worn camera footage so that this can be reviewed as part of Care UK’s 72hr immediate review process and Internal Learning Review. This is to enable us to identify issues or concerns and to assist in improving clinical care and identifying training needs.” Source location Response from Care UK
Open published response
16 May 2019 Daniel Davey · Prevention of Future Deaths report Oxfordshire
View report summary
Concerns raised 5 Failure of prison and healthcare staff to jointly manage in-possession medication risks and intervene promptly View source Failure to ensure healthcare attendance or input at ACCT reviews View source Inadequate advance notification and information sharing for ACCT reviews View source Failure to review in-possession medication risk assessments when risk changes View source Inadequate cell searching and collection of in-possession medication after a change of risk 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
Daniel Davey · 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
Daniel Davey, aged 21, died at John Radcliffe Hospital on 12 January 2018 after deliberately overdosing on propranolol in his cell at HMP Bullingdon Prison. The report raises concerns about healthcare attendance at ACCT reviews, risk assessments and management of in-possession medication, cell searches, and failures to share and act on information relevant to his safety.
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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure of prison and healthcare staff to jointly manage in-possession medication risks and intervene promptly
Wider context from the report “2. Reviews of ‘in possession’ medication risk assessments – The second concern also relates to prison and healthcare. In particular, it relates to a prisoner placed on an ACCT. I heard evidence that, initially, a template is used at the reception healthcare screen to determine if medication should be held in possession or not. I was told that, now, this is subsequently reviewed by the prescriber and, on opening an ACCT, there is an automatic review of the risk assessment in accordance with CUK’s new policy.
In the case of Mr Davey, there was an initial risk assessment at reception and he was deemed suitable for in possession medication, but this was not reviewed when he was subsequently placed on the 2 ACCT documents in December and January or when he disclosed to a mental health nurse on 29 December that he had a plan to kill himself. I understand that new systems are in place (with healthcare) but it would be reassuring if there is a system of audit to ensure compliance, namely, that the in possession risk assessments are reviewed. I appreciate a review might not necessarily result in medication being taken away. I also appreciate this is a difficult area in view of patient confidentiality and, of course, the danger that a prisoners physical or mental health could be put at risk if medication is taken away.
A related concern is the fact that prison officers did not appear to have in mind the risks associated with in possession medication . It appeared to be disregarded because it was information that was not available to them and it was therefore deemed a matter for healthcare. I am concerned that there is a danger in leaving the issue of in possession medication solely to healthcare. There could be a time delay of several hours or even longer between a prisoner having a mental health crisis and healthcare involvement/reassessment . It appears there needs to be joint liaison between the ACCT case manager and healthcare and a plan to intervene and remove medicine if necessary .
This leads to a final related concern. There is the question of cell searches for stockpiled medication and the collection of properly held in possession medication when there is a change of risk such as an ACCT document being opened. I did not hear much evidence about practice or policies relating to searching and potentially removing medication. This is clearly a task that rests with prison staff and it would be helpful to have further information about 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure healthcare attendance or input at ACCT reviews
Wider context from the report “1. Healthcare attendance at ACCT reviews – This concern relates to both the prison and healthcare. It was clear from evidence from prison and healthcare staff that it was not routine for healthcare to attend ACCT reviews . This is a significant concern and it is not in accordance with local and national policy. I understand that there were occasions when prison staff requested healthcare attendance, but no one was available . The system of providing advance notification to healthcare about the date of ACCT reviews was not comprehensive. It resulted in ACCT reviews, as in this case, taking place without information being available to the assessor/reviewer. For example, information about suicidal ideation/attempts and other information disclosed to healthcare and also information about ‘in possession medication’. Encouragingly, the evidence from prison and healthcare staff was that ACCT reviews no longer take place without healthcare attendance and/or input (perhaps over the telephone). It would be helpful if there could be a further level of reassurance provided, firstly, communications between prison and healthcare staff in the conduct of ACCT reviews and, secondly, a process of auditing ACCT reviews in order to pick up cases where there is no healthcare input.
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Inadequate advance notification and information sharing for ACCT reviews
Wider context from the report “1. Healthcare attendance at ACCT reviews – This concern relates to both the prison and healthcare. It was clear from evidence from prison and healthcare staff that it was not routine for healthcare to attend ACCT reviews. This is a significant concern and it is not in accordance with local and national policy. I understand that there were occasions when prison staff requested healthcare attendance, but no one was available. The system of providing advance notification to healthcare about the date of ACCT reviews was not comprehensive . It resulted in ACCT reviews, as in this case, taking place without information being available to the assessor/reviewer . For example, information about suicidal ideation/attempts and other information disclosed to healthcare and also information about ‘in possession medication’. Encouragingly, the evidence from prison and healthcare staff was that ACCT reviews no longer take place without healthcare attendance and/or input (perhaps over the telephone). It would be helpful if there could be a further level of reassurance provided, firstly, communications between prison and healthcare staff in the conduct of ACCT reviews and, secondly, a process of auditing ACCT reviews in order to pick up cases where there is no healthcare input.
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure to review in-possession medication risk assessments when risk changes
Wider context from the report “2. Reviews of ‘in possession’ medication risk assessments – The second concern also relates to prison and healthcare. In particular, it relates to a prisoner placed on an ACCT. I heard evidence that, initially, a template is used at the reception healthcare screen to determine if medication should be held in possession or not. I was told that, now, this is subsequently reviewed by the prescriber and, on opening an ACCT, there is an automatic review of the risk assessment in accordance with CUK’s new policy.
In the case of Mr Davey, there was an initial risk assessment at reception and he was deemed suitable for in possession medication, but this was not reviewed when he was subsequently placed on the 2 ACCT documents in December and January or when he disclosed to a mental health nurse on 29 December that he had a plan to kill himself . I understand that new systems are in place (with healthcare) but it would be reassuring if there is a system of audit to ensure compliance, namely, that the in possession risk assessments are reviewed . I appreciate a review might not necessarily result in medication being taken away. I also appreciate this is a difficult area in view of patient confidentiality and, of course, the danger that a prisoners physical or mental health could be put at risk if medication is taken away.
A related concern is the fact that prison officers did not appear to have in mind the risks associated with in possession medication. It appeared to be disregarded because it was information that was not available to them and it was therefore deemed a matter for healthcare. I am concerned that there is a danger in leaving the issue of in possession medication solely to healthcare. There could be a time delay of several hours or even longer between a prisoner having a mental health crisis and healthcare involvement/reassessment. It appears there needs to be joint liaison between the ACCT case manager and healthcare and a plan to intervene and remove medicine if necessary.
This leads to a final related concern. There is the question of cell searches for stockpiled medication and the collection of properly held in possession medication when there is a change of risk such as an ACCT document being opened. I did not hear much evidence about practice or policies relating to searching and potentially removing medication. This is clearly a task that rests with prison staff and it would be helpful to have further information about 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Inadequate cell searching and collection of in-possession medication after a change of risk
Wider context from the report “2. Reviews of ‘in possession’ medication risk assessments – The second concern also relates to prison and healthcare. In particular, it relates to a prisoner placed on an ACCT. I heard evidence that, initially, a template is used at the reception healthcare screen to determine if medication should be held in possession or not. I was told that, now, this is subsequently reviewed by the prescriber and, on opening an ACCT, there is an automatic review of the risk assessment in accordance with CUK’s new policy.
In the case of Mr Davey, there was an initial risk assessment at reception and he was deemed suitable for in possession medication, but this was not reviewed when he was subsequently placed on the 2 ACCT documents in December and January or when he disclosed to a mental health nurse on 29 December that he had a plan to kill himself. I understand that new systems are in place (with healthcare) but it would be reassuring if there is a system of audit to ensure compliance, namely, that the in possession risk assessments are reviewed. I appreciate a review might not necessarily result in medication being taken away. I also appreciate this is a difficult area in view of patient confidentiality and, of course, the danger that a prisoners physical or mental health could be put at risk if medication is taken away.
A related concern is the fact that prison officers did not appear to have in mind the risks associated with in possession medication. It appeared to be disregarded because it was information that was not available to them and it was therefore deemed a matter for healthcare. I am concerned that there is a danger in leaving the issue of in possession medication solely to healthcare. There could be a time delay of several hours or even longer between a prisoner having a mental health crisis and healthcare involvement/reassessment. It appears there needs to be joint liaison between the ACCT case manager and healthcare and a plan to intervene and remove medicine if necessary.
This leads to a final related concern. There is the question of cell searches for stockpiled medication and the collection of properly held in possession medication when there is a change of risk such as an ACCT document being opened . I did not hear much evidence about practice or policies relating to searching and potentially removing medication . This is clearly a task that rests with prison staff and it would be helpful to have further information about this.
” Open source report
21 Mar 2019 John Wright · Prevention of Future Deaths report Oxfordshire
View report summary
Concerns raised 3 Failure of the pre-arrival process to ensure receipt of high-risk self-harm or suicide information View source Lack of guidance for reducing observations of newly arrived prisoners from constant watch View source Failure to ensure that reception staff have access to all available prisoner information 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
John Wright · 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 Wright, aged 32, died at Bullingdon Prison on 15 December 2017 after being found partially suspended by an electrical cable in his cell. He had expressed suicidal thoughts and had previously been kept on constant watch, but observations were reduced to twice hourly during reception. The concerns relate to the receipt and sharing of information about heightened suicide risk and the guidance and decision-making processes for reducing observation levels.
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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure of the pre-arrival process to ensure receipt of high-risk self-harm or suicide information
Wider context from the report “The first concern which I raise applies to both the prison and healthcare and relates to the receipt of information by the prison and/or healthcare about a heightened risk of self-harm/suicide for a prisoner who has yet to arrive at prison. I heard evidence that it is not uncommon for outside agencies to pass on concerns, and, for example, copies of relevant mental health assessments, in anticipation of the prisoner arriving at the prison in a state of heightened risk requiring help and assessment. I also heard evidence that the software system operated by healthcare (System One) does not enable healthcare staff to make entries prior to the prisoner being received at reception and a prison officer opening a record on the computer and allocating a prisoner number . This being the case, I understand that the practice has been to email or print a hard copy of the document and take it to reception . In this case, a mental health nurse who was part of the secondary mental health team received a report about heightened risk and telephoned the nurse in reception to pass on details. The secondary mental health nurse said in evidence she would normally take a hard copy of the mental health assessment that she received and place it in a tray in reception. There was an alternative of emailing, but this was not considered the best way to bring it to the attention of the relevant healthcare staff in reception.
Of course, information about an incoming prisoner, who is assessed at high risk of suicide, is precisely the sort of important information which should not be allowed to fall through any gaps. It is high priority. An outside person or agency has considered it necessary to bring the matter to the attention of the prison or health care.
I understand that Care UK have set up a generic email address for healthcare staff in reception which may assist. Clearly, this still relies on healthcare staff checking to see if any such emails have been received . I appreciate that it is very busy in reception in the late afternoon/early evening.
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance for reducing observations of newly arrived prisoners from constant watch
Wider context from the report “The second matter I wish to raise, also to the prison and healthcare, is in relation to the level of observations. I heard evidence that this is often a joint responsibility held by the prison and healthcare. In this case, Mr Wright had been on constant watch, but a decision was taken during the reception process to step down to twice hourly observations. Given that staff may not have access to all available information in those first few hours, and the fact that there will not have been an opportunity for a prisoner to be observed over a significant period of time, and the fact that a more detailed assessment will not have taken place yet, there should in my view be some guidance to staff when reducing observations from constant watch .
I note that the Prison and Probation Ombudsman stated at the beginning of her report that ……. ‘Mr Wright had been under constant watch by police and court staff because he said he wanted to take his life at the earliest opportunity. Although prison staff started suicide and self-harm prevention procedures when Mr Wright arrived at Bullingdon, they reduced the level of observations from constant to twice an hour. In my view, this decision was misjudged and taken far too quickly, without a proper assessment of Mr Wright’s risk.’
I appreciate there is a great deal of responsibility on prison and healthcare staff when making assessments. Much depends on how they assess the prisoner in front of them. It may be appropriate to reduce a newly arrived prisoner from constant cell watch to less frequent observations on occasions. The concern which I raise relates to such decisions being made in reception and I enquire if there should be some guidance available to assist staff in their decision-making process? For example, should such a decision be postponed until a further assessment has been carried out the following day?
I realise that this issue is not straightforward and there are significant resource implications in keeping a prisoner under constant watch.
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure that reception staff have access to all available prisoner information
Wider context from the report “There is a related concern about the availability and sharing of such information or documentation amongst prison or health care staff in reception. From the evidence I heard at inquest, it appeared to me that the system for ensuring the staff in reception have access to all available information is in need of improvement . The senior prison officer in this case did not have all relevant information and she said that, if she had, there may have potentially been a different decision (I understand her to mean that Mr Wright may have remained on constant cell watch). I understand the Governor has created a position of ‘Head of Early Days’ and a system is in place to improve the process of documentation so that it follows the prisoner.
” 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 Consolidate self-harm and suicide-risk training through the PROTECT initiative, including comprehensive patient assessment and proactive ACCT involvement.
Verbatim wording from the response “All staff are trained to adhere to the requirements of PSI 64/2011, Management of Prisoners at risk of harm to self, to others and from others. The PSI specifies that staff should be trained at least every three years. In addition, Care UK have substantially consolidated this training with it’s PROTECT initiative which upholds standards to protect patients and maintain safety, including thoroughly assessing all patients and proactive involvement with the ACCT process. A copy of the PROTECT initiative is attached.” Source location 2019-0175-Response-by-CARE-UK
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 Implement a reception communication process using direct telephone alerts, secure email, acknowledgement and routine inbox checks for incoming patient risk information.
Verbatim wording from the response “A new process flow has been developed in partnership with the Liaison and Diversion team which specifies how to contact and share risk and special care needs information of patients from Police Custody (Via Court) to HMP Bullingdon Healthcare in Reception. The new process provides a direct telephone number to the Reception nurse from 08.00 to 20.45 Monday to Friday and 08.00-17.00 on Saturdays. The process flow now advises if there is no answer via telephone, the Reception nurse should be contacted via the prison communications room who will contact the nurse via their prison radio. Outside of these times detailed above, the prison communications team can contact the senior nurse on duty.” Source location 2019-0175-Response-by-CARE-UK
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 Provide internationally accredited ASIST training to all patient-facing staff to improve identification and management of suicide risk.
Verbatim wording from the response “Staff meetings are held every two weeks to continue to improve and share knowledge and lessons learned regarding the management of prisoners in custody. Currently HMPPS are providing specialist HMPPS training for both healthcare and discipline staff; “Understanding Risk: Why is Risk Risky?” and “Defensible Decision Making”, both of which seek to reinforce rational and appropriate decisions when applying the ACCT process and understanding suicide risk. Care UK are providing ASIST - Applied Suicide Intervention Skills Training, which is an internationally accredited and licensed 2-day course to all patient-facing staff to increase their confidence in identifying suicide risk. This improved learning, supported by SASH training will better inform decision making in all cases, including those cases where removal from constant watch is being considered.” Source location 2019-0175-Response-by-CARE-UK
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 Provide NHS email accounts to all reception staff, including agency staff, to securely access incoming risk information.
Verbatim wording from the response “All staff, including agency staff, who work in Reception have been provided with an nhs.net email account to securely access the risk information in the email. In agreement with the Liaison and Diversion service this new system went live on 25th April 2019. The requirement of a prompt made via telephone which is clearly outlined in the new process flowchart, will provide assurance to Liaison and Diversion services that their information has been effectively communicated and received by Reception staff. A copy of the process is attached.” Source location 2019-0175-Response-by-CARE-UK
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 Train staff to comply with PSI 64/2011 requirements for managing prisoners at risk of harm.
Verbatim wording from the response “All staff are trained to adhere to the requirements of PSI 64/2011, Management of Prisoners at risk of harm to self, to others and from others. The PSI specifies that staff should be trained at least every three years. In addition, Care UK have substantially consolidated this training with it’s PROTECT initiative which upholds standards to protect patients and maintain safety, including thoroughly assessing all patients and proactive involvement with the ACCT process. A copy of the PROTECT initiative is attached.” Source location 2019-0175-Response-by-CARE-UK
Open published response
23 Jan 2019 Tyrone GIVANS · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 8 Failure to maintain single, accurate NOMIS and SystmOne records View source Failure to identify missing historical records and pause later consultations View source Delays in obtaining hearing aids for deaf prisoners View source Danger posed by Spice use in prisons View source Failure to refer prisoners formally to the equalities officer View source Absence of an equalities and disabilities questionnaire on prisoner arrival View source NOMIS failing to support necessary human intervention View source Failure of discipline and healthcare staff to recognise prisoners’ deafness View source See 5 more concerns
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
Tyrone GIVANS · 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
Tyrone Givans, who was homeless, profoundly deaf and had a history of alcohol and drug use, was remanded into custody at HMP Pentonville after being arrested for assault. The jury concluded that he hanged himself in his cell, although his intentions were unclear. Principal concerns included Spice use in prison, duplicated prison and healthcare records that prevented access to earlier assessments, and inadequate recognition and support of his deafness and disabilities.
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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain single, accurate NOMIS and SystmOne records
Wider context from the report “2. A past spelling error meant that there were two sets of NOMIS prison records for Mr Givans. This meant that there were then two sets of SystmOne healthcare records .
This meant that staff did not have access to records of the assessments conducted before 8 February 2018. However, later consultations were not paused to make enquiries about this. The nature of the IT error was discovered after Mr Givans’ death, but at the time, staff did not seem to recognise the significance of having no earlier records.
Evidence was given that NOMIS in its present form is unsatisfactory and does not lend itself to human intervention. The jury found that the IT system was unfit for purpose.
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure to identify missing historical records and pause later consultations
Wider context from the report “2. A past spelling error meant that there were two sets of NOMIS prison records for Mr Givans. This meant that there were then two sets of SystmOne healthcare records.
This meant that staff did not have access to records of the assessments conducted before 8 February 2018 . However, later consultations were not paused to make enquiries about this . The nature of the IT error was discovered after Mr Givans’ death, but at the time, staff did not seem to recognise the significance of having no earlier records .
Evidence was given that NOMIS in its present form is unsatisfactory and does not lend itself to human intervention. The jury found that the IT system was unfit for purpose.
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Delays in obtaining hearing aids for deaf prisoners
Wider context from the report “3. Some members of discipline and healthcare staff did not appreciate that Mr Givans was deaf, although others did. He was not formally referred to the prison equalities officer and there was a general lack of awareness of the role of equalities officer.
There was a delay in seeking Mr Givans’ hearing aids and it took two weeks for one to be brought in by a family member . Whilst systems in HMP Pentonville have changed since Mr Givans’ death, such a situation might exist in prisons elsewhere.
There remains no equalities/disabilities questionnaire for completion on prisoners’ arrival to the prison. The first night form could be adapted, but this would be an exercise to be undertaken nationally.
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Danger posed by Spice use in prisons
Wider context from the report “1. Mr Givans’ former cell mate gave evidence that he had seen Mr Givans smoking Spice in their cell on two or three occasions, saying that its use is common within the prison. The jury heard that Spice often makes the user scared and paranoid, and can provoke immediate, extreme and uncharacteristic behaviour.
Drugs are of course a problem in all prisons and dealing with them a great challenge, but Spice poses a particular danger in all sorts of ways, both in Pentonville and across the prison estate.
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure to refer prisoners formally to the equalities officer
Wider context from the report “3. Some members of discipline and healthcare staff did not appreciate that Mr Givans was deaf, although others did. He was not formally referred to the prison equalities officer and there was a general lack of awareness of the role of equalities officer .
There was a delay in seeking Mr Givans’ hearing aids and it took two weeks for one to be brought in by a family member. Whilst systems in HMP Pentonville have changed since Mr Givans’ death, such a situation might exist in prisons elsewhere.
There remains no equalities/disabilities questionnaire for completion on prisoners’ arrival to the prison. The first night form could be adapted, but this would be an exercise to be undertaken nationally.
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Absence of an equalities and disabilities questionnaire on prisoner arrival
Wider context from the report “3. Some members of discipline and healthcare staff did not appreciate that Mr Givans was deaf, although others did. He was not formally referred to the prison equalities officer and there was a general lack of awareness of the role of equalities officer.
There was a delay in seeking Mr Givans’ hearing aids and it took two weeks for one to be brought in by a family member. Whilst systems in HMP Pentonville have changed since Mr Givans’ death, such a situation might exist in prisons elsewhere.
There remains no equalities/disabilities questionnaire for completion on prisoners’ arrival to the prison . The first night form could be adapted, but this would be an exercise to be undertaken nationally.
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation NOMIS failing to support necessary human intervention
Wider context from the report “2. A past spelling error meant that there were two sets of NOMIS prison records for Mr Givans. This meant that there were then two sets of SystmOne healthcare records.
This meant that staff did not have access to records of the assessments conducted before 8 February 2018. However, later consultations were not paused to make enquiries about this. The nature of the IT error was discovered after Mr Givans’ death, but at the time, staff did not seem to recognise the significance of having no earlier records.
Evidence was given that NOMIS in its present form is unsatisfactory and does not lend itself to human intervention . The jury found that the IT system was unfit for purpose.
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure of discipline and healthcare staff to recognise prisoners’ deafness
Wider context from the report “3. Some members of discipline and healthcare staff did not appreciate that Mr Givans was deaf , although others did. He was not formally referred to the prison equalities officer and there was a general lack of awareness of the role of equalities officer.
There was a delay in seeking Mr Givans’ hearing aids and it took two weeks for one to be brought in by a family member. Whilst systems in HMP Pentonville have changed since Mr Givans’ death, such a situation might exist in prisons elsewhere.
There remains no equalities/disabilities questionnaire for completion on prisoners’ arrival to the prison. The first night form could be adapted, but this would be an exercise to be undertaken nationally.
” 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 Change healthcare communication systems by involving senior management in unusual cases, increasing equalities referrals and recording wing conversations in medical records.
Verbatim wording from the response “Care UK acknowledges that the identification of Tyrone’s disability and the communication of his need for hearing aids, and possibly for other adjustments, could have been better handled. As the Head of Healthcare, ████████, and Deputy Head of Healthcare, ████████, explained in evidence, changes have been made to systems of communication within healthcare and between healthcare and the prison. This includes involving the input of senior management in ensuring that action is taken and information is communicated by and to the most appropriate individual where unusual situations arise; increased awareness of, and referrals to, the prison’s equalities officer and a reminder to healthcare staff regarding making notes of wing conversations in the SystmOne medical records.” Source location 2019-0028-Response-by-Care-UK
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 Implement the Health and Wellbeing model at HMP Pentonville as an additional safety net for patients entering prison.
Verbatim wording from the response “A new Health and Wellbeing model has been implemented at HMP Pentonville with effect from 14 May 2018. In addition to its primary purpose, which is to deliver primary care mental health treatment whilst preventing silo working, reducing duplicate referrals and the time patients wait to be seen and preventing patients having the same conversation multiple times to various professionals, this acts as an additional safety net for patients coming into prison. We are confident that this would have identified Tyrone’s disability and enabled better management of his care.” Source location 2019-0028-Response-by-Care-UK
Open published response
×
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 Remind clinicians to review relevant records thoroughly and query missing records or other anomalies.
Verbatim wording from the response “Clinicians have also been reminded to thoroughly review relevant records and to query apparently missing records or other anomalies. In addition, at HMP Pentonville, the structure of the clinics has been altered to minimise interruption and disruption by other patients, which transpired as a concern through GP evidence in the inquest. All healthcare reception staff at HMP Pentonville have attended a 3 day NHS England run reception screening course titled “Reducing Deaths in Custody”.” Source location 2019-0028-Response-by-Care-UK
Open published response
×
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 Work with NHS England to develop an additional equalities and disabilities safeguard in the first-night screening process.
Verbatim wording from the response “Care UK welcomes your suggestion that the first night form could be adapted to include an equalities/disabilities component. The SystmOne first night template is mandated by NHS England and whilst Care UK is more than willing to adapt the screening process, this will require discussions with NHS England. We will therefore forward your report and this response to them and work with them in the development of this additional safeguard.” Source location 2019-0028-Response-by-Care-UK
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 Continue treating and educating prisoners about the dangers of illicit drugs, including Spice, under the psychoactive-substances strategy and local procedures.
Verbatim wording from the response “Care UK acknowledges the problem presented by the supply and distribution of illicit drugs within HMP Pentonville and across the prison estate. Care UK is committed to working with partner agencies throughout the estate in supporting efforts to tackle illicit substance supply and trading, and to feed in to disciplinary, support and education processes requiring multidisciplinary team input and engagement. In addition, healthcare continue to treat and educate the prison population as to the dangers associated with the use of illicit drugs, including Spice. This management of people using psychoactive substances (PS) is supported by a Care UK’s PS strategy and Local Operating Procedures.” Source location 2019-0028-Response-by-Care-UK
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 Share learning about duplicate medical records with clinical teams through national and regional quality-assurance meetings.
Verbatim wording from the response “Care UK has shared the learning from the inquest, including the existence of the anomaly which can cause the creation of more than one set of medical records for the same patient (for example” Source location 2019-0028-Response-by-Care-UK
Open published response
×
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 Work with partner agencies to tackle illicit substance supply and support related disciplinary, education and support processes.
Verbatim wording from the response “Care UK acknowledges the problem presented by the supply and distribution of illicit drugs within HMP Pentonville and across the prison estate. Care UK is committed to working with partner agencies throughout the estate in supporting efforts to tackle illicit substance supply and trading, and to feed in to disciplinary, support and education processes requiring multidisciplinary team input and engagement. In addition, healthcare continue to treat and educate the prison population as to the dangers associated with the use of illicit drugs, including Spice. This management of people using psychoactive substances (PS) is supported by a Care UK’s PS strategy and Local Operating Procedures.” Source location 2019-0028-Response-by-Care-UK
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Adapting the mandated SystmOne first-night template requires NHS England’s involvement and cannot be undertaken unilaterally.
Verbatim wording from the response “Care UK welcomes your suggestion that the first night form could be adapted to include an equalities/disabilities component. The SystmOne first night template is mandated by NHS England and whilst Care UK is more than willing to adapt the screening process, this will require discussions with NHS England. We will therefore forward your report and this response to them and work with them in the development of this additional safeguard.” Source location 2019-0028-Response-by-Care-UK
Open published response
25 Jun 2018 Andrew Craig · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 3 Ongoing use of prescription and illicit drugs at HMP Guys Marsh View source Failure of medication-dispensing arrangements to prevent undetected transfer of prescription drugs View source Failure to monitor whether prisoners swallow dispensed medication 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
Andrew Craig · 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
Andrew Craig, a serving prisoner at HMP Guys Marsh, was found collapsed and unresponsive in his cell on 16 September 2016. The inquest concluded that the medical cause of death was the toxic effects of buprenorphine and diazepam, with a conclusion of misadventure. The principal concerns were illicit drug use at the prison and weaknesses in the dispensing and monitoring of medication, which could facilitate the redistribution of prescription drugs.
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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Ongoing use of prescription and illicit drugs at HMP Guys Marsh
Wider context from the report “i. There is an ongoing problem with the use of drugs, both prescription and illicit drugs such as psychoactive substances, at HMP Guys Marsh and there have been a number of recent deaths either confirmed to be, or suspected to be, due to drug use.
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure of medication-dispensing arrangements to prevent undetected transfer of prescription drugs
Wider context from the report “ii. Evidence was given by the Head of Healthcare, ████████ that there are 3 allocated times during the day when Prisoners collect medication. During these times, there are around 70 prisoners collecting their medication. The room can be quite chaotic and loud, and prisoners can be in close contact clambering over each other. She described the hatch as overloaded. This is an ideal scenario to pass medication to one another without detection.
iii. In addition, during the routine medication dispensing, there are no checks done to confirm that Prisoners have actually swallowed the medication. This can allow them to retain the medication for redistribution.
iv. At the last inspection by Her Majesty’s Inspectorate of Prisons these issues were raised and attempts have been made to improve the situation. There are now Prison Officers at the Healthcare department during dispensing times, but usually only one Officer stood in the room where the medication hatch is located and another outside the room. Despite these changes, Mrs Jameson advised that the arrangements at medication dispensing times continue to be an ongoing problem that facilitates the illicit supply of prescription drugs in the Prison . She advised that the process could be made safer and more secure. Similar concerns were also raised by one of the Prison GPs ████████
████████
v. Mrs Jameson also gave evidence that the Prison is overwhelmed with illicit drug use, particularly psychoactive substances and that the Healthcare team receive 3 emergency calls a week at HMP Guys Marsh to assist in resuscitating Prisoners from drug overdoses.
2. I have concerns with regard to the following:
i. There is an ongoing problem with the use of drugs, both prescription and illicit drugs such as psychoactive substances, at HMP Guys Marsh and there have been a number of recent deaths either confirmed to be, or suspected to be, due to drug use.
ii. Although the Prison are working to address this, further consideration needs to be given to restricting the supply of such drugs. I would request that to prevent a future death at HMP Guys Marsh, there is a review of the policies and procedures by both the Prison Staff and the Healthcare Staff regarding the dispensing and monitoring of the medication administered at the medication hatch to ensure compliance and reduce distribution to others.
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure to monitor whether prisoners swallow dispensed medication
Wider context from the report “ii. Evidence was given by the Head of Healthcare, ████████ that there are 3 allocated times during the day when Prisoners collect medication. During these times, there are around 70 prisoners collecting their medication. The room can be quite chaotic and loud, and prisoners can be in close contact clambering over each other. She described the hatch as overloaded. This is an ideal scenario to pass medication to one another without detection.
iii. In addition, during the routine medication dispensing, there are no checks done to confirm that Prisoners have actually swallowed the medication. This can allow them to retain the medication for redistribution.
iv. At the last inspection by Her Majesty’s Inspectorate of Prisons these issues were raised and attempts have been made to improve the situation. There are now Prison Officers at the Healthcare department during dispensing times, but usually only one Officer stood in the room where the medication hatch is located and another outside the room. Despite these changes, Mrs Jameson advised that the arrangements at medication dispensing times continue to be an ongoing problem that facilitates the illicit supply of prescription drugs in the Prison. She advised that the process could be made safer and more secure. Similar concerns were also raised by one of the Prison GPs ████████
████████
v. Mrs Jameson also gave evidence that the Prison is overwhelmed with illicit drug use, particularly psychoactive substances and that the Healthcare team receive 3 emergency calls a week at HMP Guys Marsh to assist in resuscitating Prisoners from drug overdoses.
2. I have concerns with regard to the following:
i. There is an ongoing problem with the use of drugs, both prescription and illicit drugs such as psychoactive substances, at HMP Guys Marsh and there have been a number of recent deaths either confirmed to be, or suspected to be, due to drug use.
ii. Although the Prison are working to address this, further consideration needs to be given to restricting the supply of such drugs. I would request that to prevent a future death at HMP Guys Marsh, there is a review of the policies and procedures by both the Prison Staff and the Healthcare Staff regarding the dispensing and monitoring of the medication administered at the medication hatch to ensure compliance and reduce distribution to others.
” 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 Operate CCTV surveillance and follow the adjudication process when medication diversion is observed.
Verbatim wording from the response “We are aware that medication is diverted from the Healthcare department and we have already implemented a number of factors that will help to reduce this.” Source location 2018-0194-Response-by-Care-UK_Redacted
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 Review prescribing and reduce supervised medication through the In Possession Policy.
Verbatim wording from the response “We have made some changes to our practice already to improve this situation. We have reviewed our prescribing in line with the ‘In Possession Policy’ and as a consequence, the number of prisoners in receipt of supervised medication in the morning and evening has been reduced to approximately 55 patients per medication dispensing times.” Source location 2018-0194-Response-by-Care-UK_Redacted
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 Monitor patients’ Not In Possession status through medication-management reviews and refer suitable cases to pharmacy technicians.
Verbatim wording from the response “Objective | Immediate action | To be completed by
Place written guidance on individual dispensaries to educate the purpose of the green box. | Make a poster that clearly advertises the purpose of the green box. | Healthcare — 23rd July 2018
Ensure officers enforce patient confidentiality and privacy to prevent potential bullying of vulnerable patients. | Officers to encourage prisoners to respect other prisoner’s personal space to prevent bullying and knowledge of personal information. | Prison Service
Continue to monitor Not In Possession (NIP) status of patients and change to weekly or monthly possession when safe to do so. | Review NIP patients during medication management meeting. Patients booked for review with pharmacy technicians if appropriate changes could be made.” Source location 2018-0194-Response-by-Care-UK_Redacted
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 Mark the dispensary floor and display guidance explaining the green box to support privacy and orderly medication collection.
Verbatim wording from the response “We have marked the floor in front of the dispensary with a large green box that indicates to the patients where they are able to stand, in order to respect confidentiality and allow for patient privacy.” Source location 2018-0194-Response-by-Care-UK_Redacted
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 Provide relevant healthcare staff with RCGP substance-misuse training to identify diversion techniques and related behaviours.
Verbatim wording from the response “Objective | Immediate action | Training | To be completed by
Review the role and responsibilities of the officer working within healthcare. | New Job Description that identifies the expectations and responsibilities. | n/a | Prison Service
Ensure staff have the relevant substance misuse training to identify diversion techniques and understand behaviours. | All relevant staff invited to partake in the RCGP Substance Misuse training to enhance understanding. | RCGP online substance misuse training. | Healthcare. Completed 27th June 2018
| ISMS agreed to provide a training package to all healthcare staff. | ISMS department to arrange in-house training. | November 2018” Source location 2018-0194-Response-by-Care-UK_Redacted
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 Display NHS England posters promoting the health risks of new psychoactive substance use across the prison estate.
Verbatim wording from the response “Objective | Immediate action | To be completed by
Healthcare staff to provide a bite size training first aid session. | Lead Nurse and Paramedic to provide this training. | Healthcare
| | Completed 2nd July 2018
Prison CM’s to have bespoke emergency response training. | Training arranged via external provider. Training is named as COIL (Custody Officer Immediate Life Support) | Prison Service
On-going health promotion advertised around the estate highlighting the risks of using NPS | New posters sourced from NHS England | Healthcare
| | Completed 19th July 2018” Source location 2018-0194-Response-by-Care-UK_Redacted
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Universal swallowing checks are not considered practical or appropriate because queues, the physical wall and confidentiality prevent reliable checks.
Verbatim wording from the response “Whilst we understand the diversion of medication happens we do not think it is acceptable to ask for visual evidence each time. We do not have the ability within the medication queues to ensure prisoners show us they have swallowed their medication. We have a physical wall between medical staff and the patient and would not be able to ensure this happens. Due to confidentiality reasons we do not feel it would be appropriate for officers to check patient’s mouths either. However, healthcare staff do ask to check a patient’s mouth if we have reason to believe that a patient has diverted their medication.” Source location 2018-0194-Response-by-Care-UK_Redacted
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Moving the ISMS dispensary requires investment by the prison.
Verbatim wording from the response “Plans to move the ISMS dispensary to the healthcare department have been discussed. This will enable us to dispense all controlled drugs under the same scrutiny and security as ISMS medication. However this requires investment by the prison.” Source location 2018-0194-Response-by-Care-UK_Redacted
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reducing and controlling illicit drug use within the prison is predominantly the prison service’s responsibility.
Verbatim wording from the response “This is predominantly a matter for the prison service in terms of looking at how to reduce and control the use of illicit drugs within the prison.” Source location 2018-0194-Response-by-Care-UK_Redacted
Open published response
20 Dec 2017 Craig David Royce · Prevention of Future Deaths report Essex
View report summary
Concerns raised 1 Lack of a reliable documentary system for communicating mental health referral information 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
Craig David Royce · 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
Craig Royce, who had a history of mental health problems and epilepsy, was found hanging in his prison cell on 24 December 2016. The report identified concerns that a referral to mental health services following an incident of self-harm was not made and that there was no robust documentary system for communicating such referrals. The inquest jury also considered that his risk of self-harm or suicide was not properly reviewed with appropriate precautions taken.
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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Lack of a reliable documentary system for communicating mental health referral information
Wider context from the report “There is no form/template to deal with the situation of a prisoner who needs to be referred to the mental health service. Reliance upon the transfer of this vital information to Healthcare by means of a telephone conversation could be unreliable. A robust, simple documentary system is required for the communication of such important information , namely that a prisoner needs to be referred to mental health services for an assessment to be carried out by mental health services. This would be distinct from the TAG system which caters for a brief assessment to be relayed across.
” Open source report
18 Dec 2017 MARK ANTHONY DOYLE · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 9 Lack of clear criteria and defined information for assessing fitness for transfer from F Wing View source Failure to identify and record prisoner-specific trigger factors on ACCT records View source Failure to consider relevant ACCT file material when determining observation frequency View source Lack of process for recording transfer decisions, reasons and decision-maker identity View source Failure to involve prison staff who know the prisoner in ACCT reviews View source Failure to share relevant healthcare information on prisoners’ ACCT records View source Lack of mandatory first aid training for existing prison officers View source Failure to read recent risk-relevant ACCT daily record entries during case reviews View source Poor understanding of when to contact a prisoner’s family during ACCT reviews View source See 6 more concerns
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
MARK ANTHONY DOYLE · 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
Mark Anthony Doyle was found suspended by a ligature attached to his cell window bars on 21 March 2017 and died in hospital on 28 March 2017 from injuries sustained in the suspension. The inquest identified concerns including errors in recording a significant anniversary on his ACCT, his transfer from F Wing, and a delay in responding to his cell bell. Further concerns related to ACCT review and information-sharing practices, unclear criteria and recording for transfers from F Wing, and the lack of mandatory first-aid training for existing prison officers.
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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Lack of clear criteria and defined information for assessing fitness for transfer from F Wing
Wider context from the report “(3) Decisions that prisoners are fit to be transferred from F Wing are made and conveyed to prison staff by the charge nurse on duty that morning annotating by hand a list of the prisoners on the Wing. There appears to be no clear criteria for assessing when a prisoner is fit for transfer; the information that should be considered in making this determination is left to the discretion of the decision maker ; and there is no process for recording the decision, the reasons for it or the identity of the decision maker in the prisoner’s records or otherwise.
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure to identify and record prisoner-specific trigger factors on ACCT records
Wider context from the report “(1) Although recent developments regarding multi-disciplinary involvement in ACCT case reviews and quality assurance ACCT checks are encouraging (as described to me by ████████, Head of Safer Custody), I remain concerned that the following failings were apparent in the ACCT case reviews concerning Mr Doyle conducted on 10 and 20 March 2017, but are not addressed / adequately addressed by the recent initiatives (including the new Weekly Quality Assurance Check):
• Insufficient appreciation of the importance of identifying and recording trigger factors for a particular prisoner on their ACCT inside front cover ;
• Officers undertaking case reviews without reading recent entries on the ACCT daily record relevant to risk;
• Officers determining the frequency of observation levels for an ACCT prisoner without considering relevant material in the ACCT file;
• The ACCT reviewer failing to appreciate the value of involving at least one member of the prison staff who knows the prisoner; and
• Circumstances in which a prisoner’s family could or should be contacted as part of the ACCT review process were poorly understood.
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure to consider relevant ACCT file material when determining observation frequency
Wider context from the report “(1) Although recent developments regarding multi-disciplinary involvement in ACCT case reviews and quality assurance ACCT checks are encouraging (as described to me by ████████, Head of Safer Custody), I remain concerned that the following failings were apparent in the ACCT case reviews concerning Mr Doyle conducted on 10 and 20 March 2017, but are not addressed / adequately addressed by the recent initiatives (including the new Weekly Quality Assurance Check):
• Insufficient appreciation of the importance of identifying and recording trigger factors for a particular prisoner on their ACCT inside front cover;
• Officers undertaking case reviews without reading recent entries on the ACCT daily record relevant to risk;
• Officers determining the frequency of observation levels for an ACCT prisoner without considering relevant material in the ACCT file ;
• The ACCT reviewer failing to appreciate the value of involving at least one member of the prison staff who knows the prisoner; and
• Circumstances in which a prisoner’s family could or should be contacted as part of the ACCT review process were poorly understood.
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Lack of process for recording transfer decisions, reasons and decision-maker identity
Wider context from the report “(3) Decisions that prisoners are fit to be transferred from F Wing are made and conveyed to prison staff by the charge nurse on duty that morning annotating by hand a list of the prisoners on the Wing. There appears to be no clear criteria for assessing when a prisoner is fit for transfer; the information that should be considered in making this determination is left to the discretion of the decision maker; and there is no process for recording the decision, the reasons for it or the identity of the decision maker in the prisoner’s records or otherwise .
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure to involve prison staff who know the prisoner in ACCT reviews
Wider context from the report “(1) Although recent developments regarding multi-disciplinary involvement in ACCT case reviews and quality assurance ACCT checks are encouraging (as described to me by ████████, Head of Safer Custody), I remain concerned that the following failings were apparent in the ACCT case reviews concerning Mr Doyle conducted on 10 and 20 March 2017, but are not addressed / adequately addressed by the recent initiatives (including the new Weekly Quality Assurance Check):
• Insufficient appreciation of the importance of identifying and recording trigger factors for a particular prisoner on their ACCT inside front cover;
• Officers undertaking case reviews without reading recent entries on the ACCT daily record relevant to risk;
• Officers determining the frequency of observation levels for an ACCT prisoner without considering relevant material in the ACCT file;
• The ACCT reviewer failing to appreciate the value of involving at least one member of the prison staff who knows the prisoner ; and
• Circumstances in which a prisoner’s family could or should be contacted as part of the ACCT review process were poorly understood.
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure to share relevant healthcare information on prisoners’ ACCT records
Wider context from the report “(2) Although, ████████, Head of Healthcare, described how healthcare staff have received recent encouragement to make entries on a prisoner’s ACCT in relation to matters that could bear on risk, I am concerned that this does not go far enough to change past practice and ensure that relevant information is shared , in light of the prison staff’s lack of access to System One records and the infrequent occasions that Care UK staff made entries on Mr Doyle’s ACCT daily record .
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Lack of mandatory first aid training for existing prison officers
Wider context from the report “(4) There is no mandatory first aid training for existing (as opposed to new) prison officers . I was informed that Orderly Officers and OSGs have / are being provided with first aid training, but I am concerned this remains a serious lacuna. I appreciate it is a nationally made resourcing decision and that it has been raised previously, but I raise it for further consideration; in light of the limited number of prison and nursing staff on duty overnight, there is a real prospect of medical emergencies arising where no trained first aider is available .
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure to read recent risk-relevant ACCT daily record entries during case reviews
Wider context from the report “(1) Although recent developments regarding multi-disciplinary involvement in ACCT case reviews and quality assurance ACCT checks are encouraging (as described to me by ████████, Head of Safer Custody), I remain concerned that the following failings were apparent in the ACCT case reviews concerning Mr Doyle conducted on 10 and 20 March 2017, but are not addressed / adequately addressed by the recent initiatives (including the new Weekly Quality Assurance Check):
• Insufficient appreciation of the importance of identifying and recording trigger factors for a particular prisoner on their ACCT inside front cover;
• Officers undertaking case reviews without reading recent entries on the ACCT daily record relevant to risk ;
• Officers determining the frequency of observation levels for an ACCT prisoner without considering relevant material in the ACCT file;
• The ACCT reviewer failing to appreciate the value of involving at least one member of the prison staff who knows the prisoner; and
• Circumstances in which a prisoner’s family could or should be contacted as part of the ACCT review process were poorly understood.
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Poor understanding of when to contact a prisoner’s family during ACCT reviews
Wider context from the report “(1) Although recent developments regarding multi-disciplinary involvement in ACCT case reviews and quality assurance ACCT checks are encouraging (as described to me by ████████, Head of Safer Custody), I remain concerned that the following failings were apparent in the ACCT case reviews concerning Mr Doyle conducted on 10 and 20 March 2017, but are not addressed / adequately addressed by the recent initiatives (including the new Weekly Quality Assurance Check):
• Insufficient appreciation of the importance of identifying and recording trigger factors for a particular prisoner on their ACCT inside front cover;
• Officers undertaking case reviews without reading recent entries on the ACCT daily record relevant to risk;
• Officers determining the frequency of observation levels for an ACCT prisoner without considering relevant material in the ACCT file;
• The ACCT reviewer failing to appreciate the value of involving at least one member of the prison staff who knows the prisoner; and
• Circumstances in which a prisoner’s family could or should be contacted as part of the ACCT review process were poorly understood .
” Open source report
×
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 Embed procedures for identifying and sharing relevant prisoner risks and triggers with prison staff, supported by senior-management audits.
Verbatim wording from the response “Response: Following the inquest I have reflected and reviewed healthcare processes and there have been discussions within the healthcare team. Going forward we will ensure that the Local Operating Procedures (LOPs) are embedded, with senior management undertaking audits, to ensure that where any relevant risks and triggers are identified, we will share information with the prison in the following ways:–” Source location Response from Care UK
Open published response
×
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 a Patient Wing Movement Assessment requiring senior clinical review, documented fitness decisions and reasons, regular review meetings, and communication of outcomes before transfers.
Verbatim wording from the response “Response: We agree the system described above requires improvement. We have therefore, with immediate effect, implemented a Patient Wing Movement Assessment. This is similar system to what we have in the in-patients unit as follows.” Source location Response from Care UK
Open published response
18 Dec 2017 Stephen Mark SHAYLOR · Prevention of Future Deaths report Exeter and Greater Devon
View report summary
Concerns raised 4 Reliance on continuous CCTV monitoring to detect prisoner self-harm View source Insufficient stabilisation-wing capacity for inmates needing detoxification View source Intermittent night welfare checks and ACCT observations View source Inadequacy of healthcare night welfare checks for determining whether prisoners are breathing or alive View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Stephen Mark SHAYLOR · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Stephen Mark SHAYLOR was found hanging in his cell at HMP Exeter in the early hours of 1 January 2014 and was pronounced dead at 03:35. He was on a drug stabilisation regime and subject to healthcare night welfare checks. Concerns included the inadequacy of checks conducted through cell-door hatches, the absence of continuous CCTV monitoring, and the failure to carry out the 02:00 check.
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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Reliance on continuous CCTV monitoring to detect prisoner self-harm
Wider context from the report “(3) Night welfare checks and observations on an ACCT document are at best intermittent and rely on continuous CCTV monitoring could spot a prisoner self-harming .
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Insufficient stabilisation-wing capacity for inmates needing detoxification
Wider context from the report “(1) There were 38 places available on a corridor in C4 wing as a stabilisation wing for dealing with inmates subject to Healthcare night welfare checks. Head of Residence and Safety told the Court that the Prison received between 60 – 80 inmates per week needing detox and requiring placement in C4 cells which had doors with larger windows for checking patients at night.
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Intermittent night welfare checks and ACCT observations
Wider context from the report “(3) Night welfare checks and observations on an ACCT document are at best intermittent and rely on continuous CCTV monitoring could spot a prisoner self-harming.
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Inadequacy of healthcare night welfare checks for determining whether prisoners are breathing or alive
Wider context from the report “(2) Professor Wall, substance misuse expert, said that the system for looking after these inmates was not fit for purpose and that healthcare night welfare checks (looking through a hatch in a cell door) were inadequate because it was not possible to ascertain if a prisoner was breathing/alive by this method .
” Open source report
×
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 Have healthcare staff attend ACCT reviews, record their participation, and contribute substance-misuse and detoxification risk information.
Verbatim wording from the response “3. The ACCT process is a prison process and is operated and owned by HMPPS using prison documentation. To that extent, the overview and monitoring of the ACCT process does not sit with the healthcare team. However, any member of staff working at the prison can open an ACCT if they identify risks. Healthcare staff from the SMS, primary health or mental health team will attend ACCT reviews and record this on SystmOne. Therefore, these health care staff are responsible for contributing their knowledge regarding any risk factors which may include issues pertaining to substance misuse or detox. In my previous letter I had intended to underline that the use of the night welfare check has never been intended to replace ACCT documentation. This is simply because there are many prisoners suffering from substance withdrawal who would not require an ACCT; i.e.” Source location 2017-0380-Response-by-Care-UK
Open published response
×
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 overnight welfare checks using daily printed checklists and review completed checks the following day.
Verbatim wording from the response “Night welfare checks are carried out by Health Care Assistants (HCAs). At the start of the night shift, the nurse and HCA will print off the relevant welfare check list which will show all new additions made that day, as well as those prisoners who are already on the list. HCAs will then use that list and the printed template to assist them in conducting checks overnight. A copy of the template used was provided under cover of my first letter.” Source location 2017-0380-Response-by-Care-UK
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation HMPPS owns and operates the ACCT process; healthcare staff contribute risk information but do not oversee or monitor it.
Verbatim wording from the response “3. The ACCT process is a prison process and is operated and owned by HMPPS using prison documentation. To that extent, the overview and monitoring of the ACCT process does not sit with the healthcare team. However, any member of staff working at the prison can open an ACCT if they identify risks. Healthcare staff from the SMS, primary health or mental health team will attend ACCT reviews and record this on SystmOne. Therefore, these health care staff are responsible for contributing their knowledge regarding any risk factors which may include issues pertaining to substance misuse or detox. In my previous letter I had intended to underline that the use of the night welfare check has never been intended to replace ACCT documentation. This is simply because there are many prisoners suffering from substance withdrawal who would not require an ACCT; i.e.” Source location 2017-0380-Response-by-Care-UK
Open published response
28 Mar 2017 John WILLIAMS · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 9 Failure to follow up missed second reception screens View source Insufficient training and experience to explore mental health and substance-use issues View source Lack of first aid and CPR training for prison officers View source Failure of prison officers to understand ACCT contents View source Failure of prison officers to understand code blue and code red distinctions View source Failure to accurately record self-harm or suicide assessments View source Failure to make mental health team referrals View source Failure to conduct the second reception screen View source Failure to review and record events in the ACCT document View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
John WILLIAMS · 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 Williams hanged himself while he was a prisoner at HM Prison Pentonville, after telling staff that he would do so if his perceived needs were not met rather than intending to take his life. Concerns included inaccuracies and omissions in reception screening and referrals, inadequate understanding and use of the ACCT document, insufficient training for some support staff, confusion about emergency codes, and a lack of basic first aid and CPR training among prison officers.
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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure to follow up missed second reception screens
Wider context from the report “2. There was no second reception screen conducted. If Mr Williams was not brought to healthcare staff for his second reception screen then healthcare staff needed to follow this up .
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Insufficient training and experience to explore mental health and substance-use issues
Wider context from the report “5. Mr Williams also told the member of Phoenix Futures who saw him that he felt cannabis gave him what the mental health team did not. However, the staff member felt he did not have the training or experience to explore either of these issues in greater depth .
It may be that Phoenix Futures staff would benefit from additional training, perhaps alongside prison healthcare 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Lack of first aid and CPR training for prison officers
Wider context from the report “7. The prison officers did not have even the most basic first aid and cardiopulmonary resuscitation (CPR) training . I am aware from other inquests that this is not provided at a national level.
I have written about this before. It seems a significant gap, even allowing for the fact that there are always two trained nurses on site.
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure of prison officers to understand ACCT contents
Wider context from the report “4. Mr Williams said to several members of staff that he would self harm or hang himself if he wanted something done and it was not happening quickly enough (rather than because he actually wanted to die.)
This was recorded on his assessment, care in custody, teamwork (ACCT) document. Some prison officers did not seem familiar with the very important contents of the ACCT, not even those inside cover .
The senior officer in charge on the weekend of Mr Williams’ death did not look at the inside cover or record any events within. Again, It appears there may be benefit in additional training and/or supervision.
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure of prison officers to understand code blue and code red distinctions
Wider context from the report “6. The issue of the difference between a code blue and a code red is one about which I have written before.
One senior prison officer said in evidence that if she did not know the difference between a code blue and a code red , then there would be some serious concerns. She did not.
She had been given a small card describing code blue and code red (a card which another officer kept about her person and even produced from the witness box), and she still retained that card. However, she had never considered it worthwhile to read .
She said in court that she still thought it appropriate that she had never read the card.
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure to accurately record self-harm or suicide assessments
Wider context from the report “1. The first reception nurse who saw Mr Williams when he entered HMP Pentonville gave evidence that he had no thoughts of self harm or suicide, but she recorded that he had .
It appears she may benefit from additional training and/or supervision.
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure to make mental health team referrals
Wider context from the report “3. The first reception nurse did not make the referral to the mental health team (though this took place in any event because the court diversion team had already made the referral).
I heard that it is now done automatically when that box is ticked on the system, and I wonder whether other prison healthcare providers would benefit from such a system.
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct the second reception screen
Wider context from the report “2. There was no second reception screen conducted . If Mr Williams was not brought to healthcare staff for his second reception screen then healthcare staff needed to follow this up.
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure to review and record events in the ACCT document
Wider context from the report “4. Mr Williams said to several members of staff that he would self harm or hang himself if he wanted something done and it was not happening quickly enough (rather than because he actually wanted to die.)
This was recorded on his assessment, care in custody, teamwork (ACCT) document. Some prison officers did not seem familiar with the very important contents of the ACCT, not even those inside cover.
The senior officer in charge on the weekend of Mr Williams’ death did not look at the inside cover or record any events within . Again, It appears there may be benefit in additional training and/or supervision.
” Open source report
×
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 Investigate the First Reception Health Screen referral process and associated templates to identify how referral completion can be enforced.
Verbatim wording from the response “As you heard in evidence, we have investigated the process with regard to the templates and referrals to mental health as part of the First Reception Health Screen and whether it would be possible to not being able to pass onto a second page until the task has been completed.” Source location Response from Care UK
Open published response
×
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 a revised mandatory First Reception Health Screen template requiring confirmation of mental-health referral and electronically refer directly to the mental-health in-reach team at HMP Pentonville.
Verbatim wording from the response “The investigation has been completed and the template has been changed at HMP Pentonville with immediate effect. It is now a mandatory box to say if a Mental Health referral is required and that one has been made. The referral is then made electronically directly to the mental health in-reach team. As of Friday 24 March 2017, this revised template is being followed at HMP Pentonville.” Source location Response from Care UK
Open published response
×
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 Maintain a register of missed Second Reception/Wellman assessments, arrange follow-up appointments through the Lead Nurse, and document patient refusals with scanned disclaimers.
Verbatim wording from the response “As you heard in evidence, it is the case now that a register is kept of any Second Reception/Wellman assessments that are not completed. It is then the responsibility of the Lead Nurse to arrange for the” Source location Response from Care UK
Open published response
×
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 Consider implementing the revised First Reception Health Screen template at all prisons where Care UK conducts the assessment.
Verbatim wording from the response “The investigation has been completed and the template has been changed at HMP Pentonville with immediate effect. It is now a mandatory box to say if a Mental Health referral is required and that one has been made. The referral is then made electronically directly to the mental health in-reach team. As of Friday 24 March 2017, this revised template is being followed at HMP Pentonville.” Source location Response from Care UK
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Lead Nurse is responsible for arranging follow-up and completion of missed Second Reception/Wellman assessments.
Verbatim wording from the response “As you heard in evidence, it is the case now that a register is kept of any Second Reception/Wellman assessments that are not completed. It is then the responsibility of the Lead Nurse to arrange for the” Source location Response from Care UK
Open published response
13 Mar 2017 Daphne Cherry · Prevention of Future Deaths report Gloucestershire
View report summary
Concerns raised 1 Failure of care home staff to identify when medical concerns require escalation and medical review 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
Daphne Cherry · 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
Daphne Cherry, an 83-year-old care home resident, became dehydrated after reduced fluid intake during an infection and was admitted to hospital with a severe kidney injury. She died on 22 February 2016; the principal concern was whether care home staff could identify when a medical concern required escalation and medical review.
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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure of care home staff to identify when medical concerns require escalation and medical review
Wider context from the report “(1) Whether staff at the Care Home are able to identify when a medical concern should be escalated and a medical review sought .
” Open source report
6 Dec 2016 Tedros Habtom KAHSSAY · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 15 Ineffective chest compressions during CPR View source Failure to assess breathing and perform airway manoeuvres during resuscitation View source Unavailability of a serviceable oxygen cylinder during resuscitation View source Failure of emergency healthcare lead nurses to understand code red and code blue medical emergencies View source Failure to distinguish cardiorespiratory arrest from unconsciousness during emergency assessment View source Delay in providing substantive resuscitation care after nurse arrival View source Failure to explore recorded history of depression during reception screening View source Failure to record circumstances of the index offence in the healthcare record View source Failure to obtain general practitioner records View source Failure to apply objective clinical analysis during nurse reception screening View source Failure to check pulse during resuscitation View source Insufficient airway ventilation assistance during resuscitation View source Failure to maintain clear resuscitation roles and responsibilities View source Ambiguity in reception screening questions for identifying increased-risk prisoners View source Failure to transfer person escort and forensic medical records to nurse reception screening View source See 12 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Tedros Habtom KAHSSAY · 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
Tedros Kahssay killed himself by hanging in HM Prison Pentonville about a month after being admitted on a charge of murdering his pregnant partner. Concerns included incomplete transfer and recording of information, shortcomings in reception screening, and significantly deficient and chaotic resuscitation procedures. The report states that he was already dead when resuscitation commenced, while expressing concern for other prisoners requiring first aid.
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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Ineffective chest compressions during CPR
Wider context from the report “7. The resuscitation led by the two nurses occupying the positions of primary (Hotel 7) and secondary (Hotel 12) leads for emergency healthcare in the prison that night, was significantly lacking in the following ways.
• The nurse with primary responsibility for emergency care in the prison did not have a proper understanding of the nature of a code red and a code blue prison medical emergency. (I have raised this issue in the past.)
• One minute and twelve seconds elapsed after nurse arrival before any substantive care was given. The action during that one minute and twelve seconds did not appear to progress the resuscitation attempt.
• There seemed no clear demarcation of roles and responsibilities during the resuscitation. Of course these may change as those giving resuscitation tire, but the changes seemed haphazard.
• There was no checking for breath or airway manoeuvre at the outset or at any time during the resuscitation.
• There was no checking for pulse at the outset, before commencing chest compressions, or at any time during the resuscitation.
The lead nurse attempted to justify this by saying that she had not wanted to waste time. This was despite the first action upon finding the casualty being to apply a blood pressure cuff, on the basis that this was part of the nurse assessment.
• When giving evidence, the lead nurse appeared to conflate the casualty who is in cardiorespiratory arrest with the casualty who is merely unconscious. She repeatedly talked about the need to give cardiopulmonary resuscitation (CPR) to an unconscious casualty. She said that, at the time she started chest compressions, she did not know whether Mr Kahssay was breathing or not breathing.
• When CPR was given, chest compressions were ineffective, being too quick and too shallow .
• There was only one brief attempt to use an ambubag, the majority of the resuscitation taking place without airway assistance or with a non rebreathe oxygen mask.
• It appeared that one oxygen cylinder was empty, as it had to be changed for another.
The nurse leading the resuscitation described it as chaotic. That is indeed how it appeared to me from her description and from viewing the bodycam footage.
I was and remain very gravely concerned, not in this respect for Mr Kahssay who was in fact already dead when resuscitation commenced, but for anyone else in the prison in need of first aid.
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure to assess breathing and perform airway manoeuvres during resuscitation
Wider context from the report “7. The resuscitation led by the two nurses occupying the positions of primary (Hotel 7) and secondary (Hotel 12) leads for emergency healthcare in the prison that night, was significantly lacking in the following ways.
• The nurse with primary responsibility for emergency care in the prison did not have a proper understanding of the nature of a code red and a code blue prison medical emergency. (I have raised this issue in the past.)
• One minute and twelve seconds elapsed after nurse arrival before any substantive care was given. The action during that one minute and twelve seconds did not appear to progress the resuscitation attempt.
• There seemed no clear demarcation of roles and responsibilities during the resuscitation. Of course these may change as those giving resuscitation tire, but the changes seemed haphazard.
• There was no checking for breath or airway manoeuvre at the outset or at any time during the resuscitation .
• There was no checking for pulse at the outset, before commencing chest compressions, or at any time during the resuscitation.
The lead nurse attempted to justify this by saying that she had not wanted to waste time. This was despite the first action upon finding the casualty being to apply a blood pressure cuff, on the basis that this was part of the nurse assessment.
• When giving evidence, the lead nurse appeared to conflate the casualty who is in cardiorespiratory arrest with the casualty who is merely unconscious. She repeatedly talked about the need to give cardiopulmonary resuscitation (CPR) to an unconscious casualty. She said that, at the time she started chest compressions, she did not know whether Mr Kahssay was breathing or not breathing.
• When CPR was given, chest compressions were ineffective, being too quick and too shallow.
• There was only one brief attempt to use an ambubag, the majority of the resuscitation taking place without airway assistance or with a non rebreathe oxygen mask.
• It appeared that one oxygen cylinder was empty, as it had to be changed for another.
The nurse leading the resuscitation described it as chaotic. That is indeed how it appeared to me from her description and from viewing the bodycam footage.
I was and remain very gravely concerned, not in this respect for Mr Kahssay who was in fact already dead when resuscitation commenced, but for anyone else in the prison in need of first aid.
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Unavailability of a serviceable oxygen cylinder during resuscitation
Wider context from the report “7. The resuscitation led by the two nurses occupying the positions of primary (Hotel 7) and secondary (Hotel 12) leads for emergency healthcare in the prison that night, was significantly lacking in the following ways.
• The nurse with primary responsibility for emergency care in the prison did not have a proper understanding of the nature of a code red and a code blue prison medical emergency. (I have raised this issue in the past.)
• One minute and twelve seconds elapsed after nurse arrival before any substantive care was given. The action during that one minute and twelve seconds did not appear to progress the resuscitation attempt.
• There seemed no clear demarcation of roles and responsibilities during the resuscitation. Of course these may change as those giving resuscitation tire, but the changes seemed haphazard.
• There was no checking for breath or airway manoeuvre at the outset or at any time during the resuscitation.
• There was no checking for pulse at the outset, before commencing chest compressions, or at any time during the resuscitation.
The lead nurse attempted to justify this by saying that she had not wanted to waste time. This was despite the first action upon finding the casualty being to apply a blood pressure cuff, on the basis that this was part of the nurse assessment.
• When giving evidence, the lead nurse appeared to conflate the casualty who is in cardiorespiratory arrest with the casualty who is merely unconscious. She repeatedly talked about the need to give cardiopulmonary resuscitation (CPR) to an unconscious casualty. She said that, at the time she started chest compressions, she did not know whether Mr Kahssay was breathing or not breathing.
• When CPR was given, chest compressions were ineffective, being too quick and too shallow.
• There was only one brief attempt to use an ambubag, the majority of the resuscitation taking place without airway assistance or with a non rebreathe oxygen mask.
• It appeared that one oxygen cylinder was empty , as it had to be changed for another .
The nurse leading the resuscitation described it as chaotic. That is indeed how it appeared to me from her description and from viewing the bodycam footage.
I was and remain very gravely concerned, not in this respect for Mr Kahssay who was in fact already dead when resuscitation commenced, but for anyone else in the prison in need of first aid.
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure of emergency healthcare lead nurses to understand code red and code blue medical emergencies
Wider context from the report “7. The resuscitation led by the two nurses occupying the positions of primary (Hotel 7) and secondary (Hotel 12) leads for emergency healthcare in the prison that night, was significantly lacking in the following ways.
• The nurse with primary responsibility for emergency care in the prison did not have a proper understanding of the nature of a code red and a code blue prison medical emergency . (I have raised this issue in the past.)
• One minute and twelve seconds elapsed after nurse arrival before any substantive care was given. The action during that one minute and twelve seconds did not appear to progress the resuscitation attempt.
• There seemed no clear demarcation of roles and responsibilities during the resuscitation. Of course these may change as those giving resuscitation tire, but the changes seemed haphazard.
• There was no checking for breath or airway manoeuvre at the outset or at any time during the resuscitation.
• There was no checking for pulse at the outset, before commencing chest compressions, or at any time during the resuscitation.
The lead nurse attempted to justify this by saying that she had not wanted to waste time. This was despite the first action upon finding the casualty being to apply a blood pressure cuff, on the basis that this was part of the nurse assessment.
• When giving evidence, the lead nurse appeared to conflate the casualty who is in cardiorespiratory arrest with the casualty who is merely unconscious. She repeatedly talked about the need to give cardiopulmonary resuscitation (CPR) to an unconscious casualty. She said that, at the time she started chest compressions, she did not know whether Mr Kahssay was breathing or not breathing.
• When CPR was given, chest compressions were ineffective, being too quick and too shallow.
• There was only one brief attempt to use an ambubag, the majority of the resuscitation taking place without airway assistance or with a non rebreathe oxygen mask.
• It appeared that one oxygen cylinder was empty, as it had to be changed for another.
The nurse leading the resuscitation described it as chaotic. That is indeed how it appeared to me from her description and from viewing the bodycam footage.
I was and remain very gravely concerned, not in this respect for Mr Kahssay who was in fact already dead when resuscitation commenced, but for anyone else in the prison in need of first aid.
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure to distinguish cardiorespiratory arrest from unconsciousness during emergency assessment
Wider context from the report “7. The resuscitation led by the two nurses occupying the positions of primary (Hotel 7) and secondary (Hotel 12) leads for emergency healthcare in the prison that night, was significantly lacking in the following ways.
• The nurse with primary responsibility for emergency care in the prison did not have a proper understanding of the nature of a code red and a code blue prison medical emergency. (I have raised this issue in the past.)
• One minute and twelve seconds elapsed after nurse arrival before any substantive care was given. The action during that one minute and twelve seconds did not appear to progress the resuscitation attempt.
• There seemed no clear demarcation of roles and responsibilities during the resuscitation. Of course these may change as those giving resuscitation tire, but the changes seemed haphazard.
• There was no checking for breath or airway manoeuvre at the outset or at any time during the resuscitation.
• There was no checking for pulse at the outset, before commencing chest compressions, or at any time during the resuscitation.
The lead nurse attempted to justify this by saying that she had not wanted to waste time. This was despite the first action upon finding the casualty being to apply a blood pressure cuff, on the basis that this was part of the nurse assessment.
• When giving evidence, the lead nurse appeared to conflate the casualty who is in cardiorespiratory arrest with the casualty who is merely unconscious . She repeatedly talked about the need to give cardiopulmonary resuscitation (CPR) to an unconscious casualty. She said that, at the time she started chest compressions, she did not know whether Mr Kahssay was breathing or not breathing .
• When CPR was given, chest compressions were ineffective, being too quick and too shallow.
• There was only one brief attempt to use an ambubag, the majority of the resuscitation taking place without airway assistance or with a non rebreathe oxygen mask.
• It appeared that one oxygen cylinder was empty, as it had to be changed for another.
The nurse leading the resuscitation described it as chaotic. That is indeed how it appeared to me from her description and from viewing the bodycam footage.
I was and remain very gravely concerned, not in this respect for Mr Kahssay who was in fact already dead when resuscitation commenced, but for anyone else in the prison in need of first aid.
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Delay in providing substantive resuscitation care after nurse arrival
Wider context from the report “7. The resuscitation led by the two nurses occupying the positions of primary (Hotel 7) and secondary (Hotel 12) leads for emergency healthcare in the prison that night, was significantly lacking in the following ways.
• The nurse with primary responsibility for emergency care in the prison did not have a proper understanding of the nature of a code red and a code blue prison medical emergency. (I have raised this issue in the past.)
• One minute and twelve seconds elapsed after nurse arrival before any substantive care was given . The action during that one minute and twelve seconds did not appear to progress the resuscitation attempt .
• There seemed no clear demarcation of roles and responsibilities during the resuscitation. Of course these may change as those giving resuscitation tire, but the changes seemed haphazard.
• There was no checking for breath or airway manoeuvre at the outset or at any time during the resuscitation.
• There was no checking for pulse at the outset, before commencing chest compressions, or at any time during the resuscitation.
The lead nurse attempted to justify this by saying that she had not wanted to waste time. This was despite the first action upon finding the casualty being to apply a blood pressure cuff, on the basis that this was part of the nurse assessment.
• When giving evidence, the lead nurse appeared to conflate the casualty who is in cardiorespiratory arrest with the casualty who is merely unconscious. She repeatedly talked about the need to give cardiopulmonary resuscitation (CPR) to an unconscious casualty. She said that, at the time she started chest compressions, she did not know whether Mr Kahssay was breathing or not breathing.
• When CPR was given, chest compressions were ineffective, being too quick and too shallow.
• There was only one brief attempt to use an ambubag, the majority of the resuscitation taking place without airway assistance or with a non rebreathe oxygen mask.
• It appeared that one oxygen cylinder was empty, as it had to be changed for another.
The nurse leading the resuscitation described it as chaotic. That is indeed how it appeared to me from her description and from viewing the bodycam footage.
I was and remain very gravely concerned, not in this respect for Mr Kahssay who was in fact already dead when resuscitation commenced, but for anyone else in the prison in need of first aid.
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure to explore recorded history of depression during reception screening
Wider context from the report “6. The second reception (well man) screening nurse did not explore the history of depression recorded , he said because the prison general practitioner had not prescribed any medication for depression. On reflection, the nurse thought that he should have asked about it.
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure to record circumstances of the index offence in the healthcare record
Wider context from the report “2. The index offence is recorded on the PER (and inputted onto the prison computer system NOMIS, though not the healthcare computer system SystmOne ), but not the circumstances . The circumstances – perhaps from the indictment read out in court – may be potentially helpful to healthcare and possibly also to discipline staff in prison.
This is not clear cut, because the logistics of obtaining the information and making it available to those who need it are complex; prosecutions must not be compromised; and there is the potential for making a prisoner’s mental state worse by probing the circumstances.
However, it seems that this is an issue that is worthy of consideration, preferably at a national level.
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain general practitioner records
Wider context from the report “3. The general practitioner records were never obtained (an issue that I have raised in the past), despite there being a system in place for Pentonville healthcare administrative staff to do this. Whilst that did not impact upon Mr Kahssay’s care, it might for another prisoner.
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure to apply objective clinical analysis during nurse reception screening
Wider context from the report “5. Both nurses conducting reception screening talked often in evidence about not being able to do anything other than accept the answers given by the prisoner. They did not seem to bring any objective analysis to the screening . The process of nurse screening appeared at times to be a tick box exercise .
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure to check pulse during resuscitation
Wider context from the report “7. The resuscitation led by the two nurses occupying the positions of primary (Hotel 7) and secondary (Hotel 12) leads for emergency healthcare in the prison that night, was significantly lacking in the following ways.
• The nurse with primary responsibility for emergency care in the prison did not have a proper understanding of the nature of a code red and a code blue prison medical emergency. (I have raised this issue in the past.)
• One minute and twelve seconds elapsed after nurse arrival before any substantive care was given. The action during that one minute and twelve seconds did not appear to progress the resuscitation attempt.
• There seemed no clear demarcation of roles and responsibilities during the resuscitation. Of course these may change as those giving resuscitation tire, but the changes seemed haphazard.
• There was no checking for breath or airway manoeuvre at the outset or at any time during the resuscitation.
• There was no checking for pulse at the outset, before commencing chest compressions, or at any time during the resuscitation .
The lead nurse attempted to justify this by saying that she had not wanted to waste time. This was despite the first action upon finding the casualty being to apply a blood pressure cuff, on the basis that this was part of the nurse assessment.
• When giving evidence, the lead nurse appeared to conflate the casualty who is in cardiorespiratory arrest with the casualty who is merely unconscious. She repeatedly talked about the need to give cardiopulmonary resuscitation (CPR) to an unconscious casualty. She said that, at the time she started chest compressions, she did not know whether Mr Kahssay was breathing or not breathing.
• When CPR was given, chest compressions were ineffective, being too quick and too shallow.
• There was only one brief attempt to use an ambubag, the majority of the resuscitation taking place without airway assistance or with a non rebreathe oxygen mask.
• It appeared that one oxygen cylinder was empty, as it had to be changed for another.
The nurse leading the resuscitation described it as chaotic. That is indeed how it appeared to me from her description and from viewing the bodycam footage.
I was and remain very gravely concerned, not in this respect for Mr Kahssay who was in fact already dead when resuscitation commenced, but for anyone else in the prison in need of first aid.
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Insufficient airway ventilation assistance during resuscitation
Wider context from the report “7. The resuscitation led by the two nurses occupying the positions of primary (Hotel 7) and secondary (Hotel 12) leads for emergency healthcare in the prison that night, was significantly lacking in the following ways.
• The nurse with primary responsibility for emergency care in the prison did not have a proper understanding of the nature of a code red and a code blue prison medical emergency. (I have raised this issue in the past.)
• One minute and twelve seconds elapsed after nurse arrival before any substantive care was given. The action during that one minute and twelve seconds did not appear to progress the resuscitation attempt.
• There seemed no clear demarcation of roles and responsibilities during the resuscitation. Of course these may change as those giving resuscitation tire, but the changes seemed haphazard.
• There was no checking for breath or airway manoeuvre at the outset or at any time during the resuscitation.
• There was no checking for pulse at the outset, before commencing chest compressions, or at any time during the resuscitation.
The lead nurse attempted to justify this by saying that she had not wanted to waste time. This was despite the first action upon finding the casualty being to apply a blood pressure cuff, on the basis that this was part of the nurse assessment.
• When giving evidence, the lead nurse appeared to conflate the casualty who is in cardiorespiratory arrest with the casualty who is merely unconscious. She repeatedly talked about the need to give cardiopulmonary resuscitation (CPR) to an unconscious casualty. She said that, at the time she started chest compressions, she did not know whether Mr Kahssay was breathing or not breathing.
• When CPR was given, chest compressions were ineffective, being too quick and too shallow.
• There was only one brief attempt to use an ambubag , the majority of the resuscitation taking place without airway assistance or with a non rebreathe oxygen mask .
• It appeared that one oxygen cylinder was empty, as it had to be changed for another.
The nurse leading the resuscitation described it as chaotic. That is indeed how it appeared to me from her description and from viewing the bodycam footage.
I was and remain very gravely concerned, not in this respect for Mr Kahssay who was in fact already dead when resuscitation commenced, but for anyone else in the prison in need of first aid.
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain clear resuscitation roles and responsibilities
Wider context from the report “7. The resuscitation led by the two nurses occupying the positions of primary (Hotel 7) and secondary (Hotel 12) leads for emergency healthcare in the prison that night, was significantly lacking in the following ways.
• The nurse with primary responsibility for emergency care in the prison did not have a proper understanding of the nature of a code red and a code blue prison medical emergency. (I have raised this issue in the past.)
• One minute and twelve seconds elapsed after nurse arrival before any substantive care was given. The action during that one minute and twelve seconds did not appear to progress the resuscitation attempt.
• There seemed no clear demarcation of roles and responsibilities during the resuscitation . Of course these may change as those giving resuscitation tire, but the changes seemed haphazard .
• There was no checking for breath or airway manoeuvre at the outset or at any time during the resuscitation.
• There was no checking for pulse at the outset, before commencing chest compressions, or at any time during the resuscitation.
The lead nurse attempted to justify this by saying that she had not wanted to waste time. This was despite the first action upon finding the casualty being to apply a blood pressure cuff, on the basis that this was part of the nurse assessment.
• When giving evidence, the lead nurse appeared to conflate the casualty who is in cardiorespiratory arrest with the casualty who is merely unconscious. She repeatedly talked about the need to give cardiopulmonary resuscitation (CPR) to an unconscious casualty. She said that, at the time she started chest compressions, she did not know whether Mr Kahssay was breathing or not breathing.
• When CPR was given, chest compressions were ineffective, being too quick and too shallow.
• There was only one brief attempt to use an ambubag, the majority of the resuscitation taking place without airway assistance or with a non rebreathe oxygen mask.
• It appeared that one oxygen cylinder was empty, as it had to be changed for another.
The nurse leading the resuscitation described it as chaotic. That is indeed how it appeared to me from her description and from viewing the bodycam footage.
I was and remain very gravely concerned, not in this respect for Mr Kahssay who was in fact already dead when resuscitation commenced, but for anyone else in the prison in need of first aid.
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Ambiguity in reception screening questions for identifying increased-risk prisoners
Wider context from the report “4. The first reception screen template contained questions that carried an inherent ambiguity , in that they related to a change in personal and family circumstances, which must always be the case when a person is incarcerated and therefore does not assist in determining which prisoners are at an increased 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure to transfer person escort and forensic medical records to nurse reception screening
Wider context from the report “1. The person escort record (PER) and appended report of the forensic medical examiner (FME) that accompanied Mr Kahssay to HMP Pentonville did not accompany him to nurse reception screening .
” 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 Replace the reception templates with an auditable, task-driven referral pathway that assigns greater accountability to the screening clinician.
Verbatim wording from the response “Concern 4. The first reception screen template contained questions that carried an inherent ambiguity, in that they related to a change in personal and family circumstances, which must always be the case when a person is incarcerated and therefore does not assist in determining which prisoners are at an increased risk.” Source location 2016-0437-Response-by-Care-UK.pdf
Open published response
×
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 Roll out the wellbeing wheel assessment, supported by online and face-to-face training, to explore mental health, physical health and substance-misuse issues in greater depth.
Verbatim wording from the response “We accept that the nurse could have explored the history of depression in greater detail. Our secondary reception screening process provides more time for this and we are in process of rolling out our wellbeing wheel assessment to support this assessment. The wellbeing wheel provides a structure for clinical staff to explore mental health issues in more depth alongside” Source location 2016-0437-Response-by-Care-UK.pdf
Open published response
×
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 Discuss resuscitation and emergency-bag issues regularly during Friday afternoon healthcare training sessions.
Verbatim wording from the response “In addition to this, the healthcare team plan to discuss issues relating to resuscitation and use of emergency bags regularly in their Friday afternoon training sessions. A SOP for emergency response is in development by the national team and is due for circulation shortly.” Source location 2016-0437-Response-by-Care-UK.pdf
Open published response
×
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 Develop and circulate a standard operating procedure for emergency response.
Verbatim wording from the response “In addition to this, the healthcare team plan to discuss issues relating to resuscitation and use of emergency bags regularly in their Friday afternoon training sessions. A SOP for emergency response is in development by the national team and is due for circulation shortly.” Source location 2016-0437-Response-by-Care-UK.pdf
Open published response
×
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 Request 250 additional emergency-response aide-memoire cards for distribution across the establishment.
Verbatim wording from the response “The use and meaning of Code Red and Code Blue has again been strongly reinforced to the nursing staff. Training sessions have taken place for all the staff and attendance sheets have been collected. Posters re-affirming the criteria of Code Red and Code Blue were displayed in clinical areas in December 2016. Furthermore, Safer Custody have been requested to re-order 250 of the aide-memoire cards for distribution across the establishment.” Source location 2016-0437-Response-by-Care-UK.pdf
Open published response
×
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 Replace the prescriptive self-harm and suicide risk score with clinician-led exploration of presentation and relevant risk factors.
Verbatim wording from the response “You heard evidence with regard to the new reception screening template and process. The scoring system in relation to the risk of self-harm or suicide has now gone as this was found to be too prescriptive. The focus is now placed on the member of healthcare who is screening the patient to explore the presentation and look into factors that may be relevant to suicide and or self-harm.” Source location 2016-0437-Response-by-Care-UK.pdf
Open published response
×
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 Reinforce Code Red and Code Blue procedures through staff training and clinical-area posters.
Verbatim wording from the response “The use and meaning of Code Red and Code Blue has again been strongly reinforced to the nursing staff. Training sessions have taken place for all the staff and attendance sheets have been collected. Posters re-affirming the criteria of Code Red and Code Blue were displayed in clinical areas in December 2016. Furthermore, Safer Custody have been requested to re-order 250 of the aide-memoire cards for distribution across the establishment.” Source location 2016-0437-Response-by-Care-UK.pdf
Open published response
×
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 Check that all Care UK clinical staff receive mandatory intermediate life-support training.
Verbatim wording from the response “All clinical staff that are employed by Care UK have ILS as a mandatory training requirement. A check has been undertaken to ensure that all Care UK clinical staff are receiving the ILS training. This has been confirmed to be the case.” Source location 2016-0437-Response-by-Care-UK.pdf
Open published response
×
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 Obtain consent for general practitioner records during reception screening and trigger an auditable SystmOne task for administrative staff to request them.
Verbatim wording from the response “As you heard in evidence, consent for the obtaining of general practitioner records is now sought as part of the reception screen and it is also a mandatory field that needs to be completed by the member of healthcare prior to finishing the screen. When consent is taken, the screening tool requires a task be sent to the Administrative staff to make them aware that” Source location 2016-0437-Response-by-Care-UK.pdf
Open published response
×
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 Require nurses to confirm they have seen the person escort record and possess the CSRA and PER before completing reception screening.
Verbatim wording from the response “As you heard in evidence at the inquest, the reception screening template has been changed. The change that has been implemented is a control question in the first reception screen which is a mandatory field so the nurse needs to stop and answer the question. It asks if the nurse has seen the PER. All nursing staff have been instructed and are aware that they are not to screen any prisoner without a CSRA and PER as minimum requirement to aid screening.” Source location 2016-0437-Response-by-Care-UK.pdf
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation GP practices cannot be guaranteed to send requested medical records, limiting the ability to obtain them.
Verbatim wording from the response “Whilst we have a system in place to request medical records and follow up, it is important to highlight that we cannot ensure that a GP practice will send records to us. It is anticipated that this is an issue which will be eased once the new clinical IT system is in place providing access to the NHS spine and patients Summary Care Records.” Source location 2016-0437-Response-by-Care-UK.pdf
Open published response
26 Jul 2016 Terence Darren ADAMS · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 9 Delays and failures in disclosing root cause analyses to the coroner View source Failure to explore potential triggers for disclosed suicidal thoughts View source Unavailability of the first night reception template key to the assessing GP View source Failure of the assessing GP to recognise the inpatient healthcare threshold in the first night reception template View source Failure to follow up non-attendance at the second reception screen View source Failure to share root cause analyses with relevant internal safety and healthcare leaders View source Failure to check prison escort records for required attachments View source Failure to ensure staff understand the status of the first night reception template View source Failure of the first night reception template to indicate that its instructions are advisory rather than mandatory View source See 6 more concerns
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
Terence Darren ADAMS · 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
Terence Darren Adams committed suicide by hanging himself in his cell at HM Prison Pentonville. Concerns included failures in checking prison escort records, understanding and acting on the first night reception template, exploring his suicidal history, ensuring attendance at a follow-up reception screen, and sharing the root cause analysis needed for learning lessons.
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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Delays and failures in disclosing root cause analyses to the coroner
Wider context from the report “6. The root cause analysis (RCA) conducted by Care UK after Mr Adams’ death in November 2015, and finalised in February 2016, was not shared with HM Coroner until part way through the inquest , and then only following the accidental discovery of its existence by two of the inquest advocates. It had not been shared with HMP Pentonville’s head of safer custody governor; nor even with the deputy head of healthcare of Care UK itself. Its existence had not been disclosed to HM Coroner .
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure to explore potential triggers for disclosed suicidal thoughts
Wider context from the report “4. Mr Adams told the GP that he had been suicidal on and off for twenty years, but she did not explore with him the potential triggers for this . In fact, one such trigger was incarceration.
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Unavailability of the first night reception template key to the assessing GP
Wider context from the report “2. The general practitioner (GP) who saw Mr Adams when he first arrived at HMP Pentonville did not have the key for the first night reception template when she considered the information contained therein. Mr Adams scored 8. The GP did not know that the advice on the template for scores of 6 and over was to admit the prisoner to inpatient healthcare.
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure of the assessing GP to recognise the inpatient healthcare threshold in the first night reception template
Wider context from the report “2. The general practitioner (GP) who saw Mr Adams when he first arrived at HMP Pentonville did not have the key for the first night reception template when she considered the information contained therein. Mr Adams scored 8. The GP did not know that the advice on the template for scores of 6 and over was to admit the prisoner to inpatient healthcare .
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure to follow up non-attendance at the second reception screen
Wider context from the report “5. On the morning he died, Mr Adams should have attended his second reception screen, also known as the well man clinic. When he did not arrive, the healthcare nurse did not attempt to find out why or to secure his attendance .
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure to share root cause analyses with relevant internal safety and healthcare leaders
Wider context from the report “6. The root cause analysis (RCA) conducted by Care UK after Mr Adams’ death in November 2015, and finalised in February 2016, was not shared with HM Coroner until part way through the inquest, and then only following the accidental discovery of its existence by two of the inquest advocates. It had not been shared with HMP Pentonville’s head of safer custody governor; nor even with the deputy head of healthcare of Care UK itself . Its existence had not been disclosed to HM Coroner.
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure to check prison escort records for required attachments
Wider context from the report “1. I heard at inquest that the prison escort record (PER) that accompanies each prisoner to HMP Pentonville (and which in the future will be forwarded to healthcare staff), is not checked on arrival and thereafter to ensure that, as it progresses through the prison, it includes the attachments described within the document , for example the risk assessment conducted by the police. This seems an unhelpful omission.
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure staff understand the status of the first night reception template
Wider context from the report “3. Neither the nurse nor the GP conducting the first night reception interviews was clear about the status of the first night reception template . The nurse, particularly, talked about it being a document referring to historical matters, whereas the reality is that it encompasses both past and relevant current issues. The document did not give any indication on the face of it that its instructions are advisory rather than mandatory.
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure of the first night reception template to indicate that its instructions are advisory rather than mandatory
Wider context from the report “3. Neither the nurse nor the GP conducting the first night reception interviews was clear about the status of the first night reception template. The nurse, particularly, talked about it being a document referring to historical matters, whereas the reality is that it encompasses both past and relevant current issues. The document did not give any indication on the face of it that its instructions are advisory rather than mandatory .
” 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 Automatically provide redacted root-cause analyses of relevant deaths to the prison Governor going forward.
Verbatim wording from the response “RCAs are shared with NHS England as Commissioner (but staff names are redacted). We recognise that RCAs should be share in an open and transparent manner and the prison Governor will automatically receive (redacted) copies going forward. The findings of all RCA’s should be shared, reviewed and discussed during individual site Quality Assurance Meetings. This is the forum where Action plans should be agreed on and progressed forward. The importance of this will be presented by the in-house legal team at our next divisional Quality Assurance meeting.” Source location Response from Care UK
Open published response
×
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 Roll out refresher training on the first-night reception template and its clinical guidance to all staff.
Verbatim wording from the response “Response: This information was available in SystmOne for the General Practitioner. As a result of it having been overlooked, we will be rolling out a program of refresher training to all staff” Source location Response from Care UK
Open published response
×
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 Review, approve and implement a revised first-night mental-health risk assessment with staff training, SystmOne integration and advisory clinical-judgement guidance.
Verbatim wording from the response “Response: There is an expectation that nurses undertaking reception duties within the prison complete an assessment of a person’s current risk of self-harm and suicidality when they are initially received into custody. This is particularly relevant as it is known that, for some prisoners, the early days of custody prove particularly stressful and so increase their risk. You heard the evidence of the Deputy Head of Healthcare who explained that, following another recent death in custody, we were already undertaking a review of the current risk assessment that is in use in reception in an attempt to improve its efficacy.” Source location Response from Care UK
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Nurses cannot chase prisoners who miss appointments during clinics because workload makes this impractical and inefficient.
Verbatim wording from the response “When a patient is booked for a clinic but does not attend (DNA), nurses will investigate and chase up that person once the clinic is over. It would not be possible, nor an efficient use of clinical time, for nurses to chase up prisoners during the course of a clinic. With 15-20 new receptions everyday (Pentonville being a remand prison and thus having a high population turnover), if nurses chased up DNA prisoners during the course of the clinic, they would spend their time doing nothing else.” Source location Response from Care UK
Open published response
22 Jul 2016 Alan George Stead · Prevention of Future Deaths report Staffordshire South
View report summary
Concerns raised 2 Delays in testing blood samples from prisoners View source Delays in taking blood samples from prisoners View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Alan George Stead · 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 George Stead, a serving prisoner at HMP Dovegate, became ill late on 20 January 2016 and died shortly after arriving at hospital. The principal concern was delays in taking and testing prisoners’ blood samples at HMP Dovegate, which could have serious consequences in some cases.
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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Delays in testing blood samples from prisoners
Wider context from the report “(1) The medical review has identified delays with the taking and testing of blood samples from prisoners at HMP Dovegate. This was not something included in a recommendation in the PPO report but was expressed as a concern by the family at the Inquest. This could have serious consequences in some cases. I wonder if you have looked at this and have done or can do anything to improve the situation with this at HMP Dovegate and indeed at any other prisons where you provide healthcare if this is an issue.
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Delays in taking blood samples from prisoners
Wider context from the report “(1) The medical review has identified delays with the taking and testing of blood samples from prisoners at HMP Dovegate. This was not something included in a recommendation in the PPO report but was expressed as a concern by the family at the Inquest. This could have serious consequences in some cases. I wonder if you have looked at this and have done or can do anything to improve the situation with this at HMP Dovegate and indeed at any other prisons where you provide healthcare if this is an issue.
” 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 Send blood samples to the hospital laboratory each afternoon on the day they are taken.
Verbatim wording from the response “On 14 December 2015 a programme was introduced at HMP Dovegate for all nurses and HCAs to be trained in phlebotomy. This programme was completed and all of the staff were deemed competent and signed off in March 2016. Now, blood tests are conducted as soon as required and on the same day whenever possible or if flagged urgent. If they are not performed on the day, patients are added onto a waiting list of a few days. Blood samples are sent to the hospital laboratory the day each afternoon.” Source location 2016-0261-Response-by-Care-UK
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 Conduct required blood tests promptly, using same-day testing where possible and a short waiting list when same-day testing is unavailable.
Verbatim wording from the response “On 14 December 2015 a programme was introduced at HMP Dovegate for all nurses and HCAs to be trained in phlebotomy. This programme was completed and all of the staff were deemed competent and signed off in March 2016. Now, blood tests are conducted as soon as required and on the same day whenever possible or if flagged urgent. If they are not performed on the day, patients are added onto a waiting list of a few days. Blood samples are sent to the hospital laboratory the day each afternoon.” Source location 2016-0261-Response-by-Care-UK
Open published response
×
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 Train and competency-sign off all nurses and healthcare assistants in phlebotomy at HMP Dovegate.
Verbatim wording from the response “On 14 December 2015 a programme was introduced at HMP Dovegate for all nurses and HCAs to be trained in phlebotomy. This programme was completed and all of the staff were deemed competent and signed off in March 2016. Now, blood tests are conducted as soon as required and on the same day whenever possible or if flagged urgent. If they are not performed on the day, patients are added onto a waiting list of a few days. Blood samples are sent to the hospital laboratory the day each afternoon.” Source location 2016-0261-Response-by-Care-UK
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The delayed blood test would not have affected Mr Stead’s death or resulted in different treatment.
Verbatim wording from the response “As noted by the independent clinical reviewer, this blood test would not have had an impact on Mr Stead’s death on 21 January and an earlier test would not have resulted in Mr Stead receiving any different treatment.” Source location 2016-0261-Response-by-Care-UK
Open published response
19 May 2016 Samuel Rodney Darren BLAIR · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 16 Failure to refer antidepressant history to a prison GP View source Failure to enter collateral history into the main clinical records View source Failure to record assessment of mood and suicidal thoughts during prison triage View source Failure to assess drug use during prison triage View source Failure to consider continuation of prescribed citalopram View source Failure to record consideration or a management plan for depression View source Delay in providing the ambulance with the prison gate location View source Inconsistent understanding of prison healthcare emergency procedures View source Out-of-date intermediate life support certification View source Delay in emergency nurse attendance at the patient’s side View source Failure to record discussion or a management plan for schizophrenia View source Failure to recognise prior compliant antidepressant treatment View source Restricted immediate access to the emergency defibrillator View source Failure to promptly acknowledge emergency radio calls View source Lack of current mandatory basic life support and first aid training for all prison officers View source Failure to re-check the pulse during resuscitation View source See 13 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Samuel Rodney Darren BLAIR · 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
Rodney Blair, who had a history of paranoid schizophrenia, alcohol dependency, multiple drug use and depression, was remanded in custody at HM Prison Pentonville and was found hanging in his cell on 2 August 2015. The inquest concluded that his death was suicide, with several contributing factors. Concerns included gaps in assessment and management of his mental health and antidepressant treatment, and delays and procedural issues in the prison emergency response.
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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure to refer antidepressant history to a prison GP
Wider context from the report “4. There is no record from that meeting or any other time, of any consideration of or management plan for Mr Blair’s depression.
Most particularly, there is no record that it was ever recognised by the healthcare staff at HMP Pentonville that Mr Blair had been prescribed and had been compliant with the prescription of an anti depressant before his incarceration.
The assistant psychologist who obtained the history of a prescription of anti depressant medication did not refer Mr Blair to a prison GP for consideration of this .
Mr Blair was never offered any continuation of his citalopram prescription. The plan in the community had been to continue the prescription, but there is no record that this was ever considered by healthcare staff at HMP Pentonville.
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure to enter collateral history into the main clinical records
Wider context from the report “2. She later uploaded to the computer system the collateral history she had been sent as a Word document, but did not input any of it into the main body of the records , nor did the psychiatrist who made the note at the multi disciplinary team meeting in prison on 7 July 2015 at which Mr Blair was discussed.
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure to record assessment of mood and suicidal thoughts during prison triage
Wider context from the report “1. Although the assistant psychologist who triaged Mr Blair in prison on 2 July 2015 asked him about his alcohol dependency, she did not ask him about drug use, nor did she record asking him about his mood or any suicidal thoughts.
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure to assess drug use during prison triage
Wider context from the report “1. Although the assistant psychologist who triaged Mr Blair in prison on 2 July 2015 asked him about his alcohol dependency, she did not ask him about drug use , nor did she record asking him about his mood or any suicidal thoughts.
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure to consider continuation of prescribed citalopram
Wider context from the report “4. There is no record from that meeting or any other time, of any consideration of or management plan for Mr Blair’s depression.
Most particularly, there is no record that it was ever recognised by the healthcare staff at HMP Pentonville that Mr Blair had been prescribed and had been compliant with the prescription of an anti depressant before his incarceration.
The assistant psychologist who obtained the history of a prescription of anti depressant medication did not refer Mr Blair to a prison GP for consideration of this.
Mr Blair was never offered any continuation of his citalopram prescription . The plan in the community had been to continue the prescription, but there is no record that this was ever considered by healthcare staff at HMP Pentonville .
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure to record consideration or a management plan for depression
Wider context from the report “4. There is no record from that meeting or any other time, of any consideration of or management plan for Mr Blair’s depression .
Most particularly, there is no record that it was ever recognised by the healthcare staff at HMP Pentonville that Mr Blair had been prescribed and had been compliant with the prescription of an anti depressant before his incarceration.
The assistant psychologist who obtained the history of a prescription of anti depressant medication did not refer Mr Blair to a prison GP for consideration of this.
Mr Blair was never offered any continuation of his citalopram prescription. The plan in the community had been to continue the prescription, but there is no record that this was ever considered by healthcare staff at HMP Pentonville.
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Delay in providing the ambulance with the prison gate location
Wider context from the report “5. After Mr Blair was found hanging, the officer in the prison control room did not give the prison gate location for the ambulance at the very outset of the 999 call to London Ambulance Service, but instead did so part way through the call.
The LAS controller did not ask at the very outset.
The ideal would be for the information to be given at the very beginning of any emergency call .
(I wrote to HMP Pentonville on 16 September 2016 in connection with the death of another prisoner about this issue. I appreciate that work on this matter is ongoing.)
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Inconsistent understanding of prison healthcare emergency procedures
Wider context from the report “9. That nurse gave a description of the code blue and code red system of describing an emergency, that was markedly different from the understanding given by the prison governor and the London Ambulance Service . I heard that the codes blue and red are even described on posters within the prison.
It therefore appears that a nurse within the prison healthcare team has the wrong understanding of basic prison healthcare emergency procedures .
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Out-of-date intermediate life support certification
Wider context from the report “8. That nurse (a mental health, rather than general nurse) began resuscitation. He gave evidence that he started chest compressions and continued these for two minutes until a custodial manager arrived, without any intention of ever stopping to re-check Mr Blair’s pulse.
He said that, whilst his basic life support certification was current at the time of Mr Blair’s death, his intermediate life support certification was not, and is still not ; it is currently at least three years out of date .
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Delay in emergency nurse attendance at the patient’s side
Wider context from the report “6. The prison nurse on call for emergencies, call sign Hotel 7, who was called to attend Mr Blair after he had been found hanging, did not acknowledge the radio call for several minutes, despite numerous attempts by prison control.
When she finally did acknowledge the emergency, there was a delay of up to approximately 15 minutes before she was at Mr Blair’s side .
(I wrote to HMP Pentonville on 16 September 2016 in connection with the death of another prisoner about a different nurse, but also in the role of Hotel 7, who did not respond to an emergency alarm as soon as it was activated.)
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure to record discussion or a management plan for schizophrenia
Wider context from the report “3. There is no record from that meeting of any discussion or management plan for Mr Blair’s schizophrenia .
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise prior compliant antidepressant treatment
Wider context from the report “4. There is no record from that meeting or any other time, of any consideration of or management plan for Mr Blair’s depression.
Most particularly, there is no record that it was ever recognised by the healthcare staff at HMP Pentonville that Mr Blair had been prescribed and had been compliant with the prescription of an anti depressant before his incarceration .
The assistant psychologist who obtained the history of a prescription of anti depressant medication did not refer Mr Blair to a prison GP for consideration of this.
Mr Blair was never offered any continuation of his citalopram prescription. The plan in the community had been to continue the prescription, but there is no record that this was ever considered by healthcare staff at HMP Pentonville.
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Restricted immediate access to the emergency defibrillator
Wider context from the report “7. The substance misuse nurse in the detoxification wing did respond immediately. He took his emergency bag with him to Mr Blair’s cell, but did not take the defibrillator stored in the same room as the bag . He later had to leave Mr Blair to retrieve the defibrillator , because it is stored in the nurses’ room and only nurses have the key .
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure to promptly acknowledge emergency radio calls
Wider context from the report “6. The prison nurse on call for emergencies, call sign Hotel 7, who was called to attend Mr Blair after he had been found hanging, did not acknowledge the radio call for several minutes, despite numerous attempts by prison control .
When she finally did acknowledge the emergency, there was a delay of up to approximately 15 minutes before she was at Mr Blair’s side.
(I wrote to HMP Pentonville on 16 September 2016 in connection with the death of another prisoner about a different nurse, but also in the role of Hotel 7, who did not respond to an emergency alarm as soon as it was activated.)
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Lack of current mandatory basic life support and first aid training for all prison officers
Wider context from the report “The prison officers who found Mr Blair hanging did not have current basic life support training and so were not able to commence cardiopulmonary resuscitation (CPR) before the arrival of nurses . One officer tried to take Mr Blair’s pulse, but was unclear about the correct procedure for this .
This is a situation that I have noted before at HMP Pentonville. I have not made a prevention of future deaths report in the past, because I am aware that the fact that there is no mandatory first aid (including CPR) training for all prison officers is a nationally made, resource led decision.
However, it seems to me that you, as the decision maker regarding not providing such training, should be aware of the impact that this may have on the prison population.
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure to re-check the pulse during resuscitation
Wider context from the report “8. That nurse (a mental health, rather than general nurse) began resuscitation. He gave evidence that he started chest compressions and continued these for two minutes until a custodial manager arrived, without any intention of ever stopping to re-check Mr Blair’s pulse .
He said that, whilst his basic life support certification was current at the time of Mr Blair’s death, his intermediate life support certification was not, and is still not; it is currently at least three years out of date.
” 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 Implement the emergency-procedure actions outlined in the action table for all healthcare staff.
Verbatim wording from the response “Response & Actions:” Source location 2016-0196-Response-by-Care-Uk
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 Deliver an ILS training plan for most healthcare staff by December 2016 and provide annual refresher training.
Verbatim wording from the response “Care UK Cardiopulmonary (CPR) Resuscitation Policy in the Training section (section 7) states:” Source location 2016-0196-Response-by-Care-Uk
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation BEH-MHT is responsible for concerns relating to its mental health services and will provide the relevant response and action plan.
Verbatim wording from the response “Response: We refer to the response provided by BEH-MHT and we will collaborate with them to ensure that the action plan outlined in their response is implemented and that all healthcare staff are aware of the plan.” Source location 2016-0196-Response-by-Care-Uk
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The prison is responsible for concern 5 and must provide the response.
Verbatim wording from the response “Response: This concern is a matter for the prison and accordingly, we will leave it for them to respond.” Source location 2016-0196-Response-by-Care-Uk
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Concerns 2, 3 and 4 relate to BEH-MHT services rather than the services addressed by this response.
Verbatim wording from the response “Response: We refer you to the response provided by BEH-MHT as these concerns are relating to their services rather than the services of Care UK.” Source location 2016-0196-Response-by-Care-Uk
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Any emergency response delay was justified because the nurse was treating another patient and another clinician was already attending.
Verbatim wording from the response “In any event, any delay on the part of Hotel 7 was as a result of her being located in a different wing and treating another patient following another incident. It would therefore have been entirely correct to ensure that her patient was clinically stable before leaving to attend another incident where a clinician was already in attendance.” Source location 2016-0196-Response-by-Care-Uk
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The emergency nurse’s response took less than 15 minutes, contrary to the concern’s stated delay.
Verbatim wording from the response “Response: We set out below a timeframe which we have compiled from the written evidence and with reference to the evidence heard at the inquest hearing and which suggests that the time taken was less than 15 minutes.” Source location 2016-0196-Response-by-Care-Uk
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The nurse acted within his competence because BLS-trained staff were not expected to check a pulse under applicable guidance.
Verbatim wording from the response “The nurse concerned was trained in Basic Life Support (BLS) but not Intermediate Life Support (ILS). As such, staff trained to BLS level are not expected to check a pulse as per the Resuscitation Council UK 2015 guideline. The nurse was therefore acting within the scope of his practice and competence. However, as detailed in the table below, we have implemented a training plan to ensure that, by December 2016, most healthcare staff will be ILS trained and that refresher trainings will occur yearly.” Source location 2016-0196-Response-by-Care-Uk
Open published response
27 Apr 2016 Ernest Higgs · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 3 Failure to ensure telephone clinical advice is accurately recorded and communicated in writing View source Lack of clarity about responsibility for recording visiting GPs' advice in multidisciplinary notes View source Unclear out-of-hours pathology laboratory provision for community care providers 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
Ernest Higgs · 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
Ernest Higgs, a resident of a nursing home, was admitted to hospital after his health deteriorated and died there on 20 January 2015 from aspiration pneumonia. Concerns included unclear and poorly recorded telephone advice from a GP, uncertainty over responsibility for recording clinical advice, and conflicting information about out-of-hours pathology services that contributed to a delay in blood testing.
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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure telephone clinical advice is accurately recorded and communicated in writing
Wider context from the report “(2) Advice given by the GP over the telephone to make Mr Higgs “nil by mouth” was not recorded and no confirmation of that advice in writing was sent by email . There did not appear to be a safe system in place to ensure telephone advice was accurately sent and received.
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about responsibility for recording visiting GPs' advice in multidisciplinary notes
Wider context from the report “(1) It was clear from the evidence that confusion arose over what advice had been given by the GP on the 15th January 2015. No record was made in the multi-disciplinary notes by the GP of her attendance at Milner House. Care UK the parent company of Milner House offered to liaise with their local surgeries to ensure the records were made by visiting GPs. However it appears that the BMA advice to GPs “Quality First Managing Workload To Deliver Safer Patient Care” advises against GPs filling in multi-disciplinary notes. There was no clarity about whose responsibility it was to fill in the notes.
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Unclear out-of-hours pathology laboratory provision for community care providers
Wider context from the report “(3) There was conflicting evidence from Care UK and Epsom hospital about OOH provision at the hospital pathology laboratory for community care providers resulting in a significant delay to a diagnostic blood test being undertaken.
” Open source report
Concerns raised 6 Failure to question unexplained SASH form transmission View source Lack of clarity about the designated recipient of SASH forms View source Failure of reception procedures under foreseeable high-demand conditions View source Failure of GEOAmey and prison reception staff to understand and keep each other informed about interconnecting procedures View source Failure of GEOAmey, prison and healthcare procedures to inter-operate safely View source Lack of a detailed, documented and tracked account of SASH form transmission 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.
×
AI-generated summary
Derek 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
Derek Thomas died by suicide while in HMP Durham after arriving on remand and undergoing reception and first-night induction. Information suggesting suicidal intent was not adequately communicated or identified because of failures involving the SASH and PER forms across escort, prison reception and healthcare staff. The report raised concerns about procedures failing under demanding but foreseeable conditions, unclear inter-agency responsibilities, inadequate tracking of information, and poor interoperability between agencies.
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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure to question unexplained SASH form transmission
Wider context from the report “(3) That Prison reception staff in their evidence were adamant that a SASH form could never have been overlooked. However, prison staff at every level could provide no detailed, documented and tracked, account for how the SASH form had reached the prison records for Mr Thomas. There is an over reliance on the fidelity of the system, even when it has failed. No questions were asked at any stage on 21st July 2014, when it it passed from GEOAmey staff, to reception staff, to healthcare, or thereafter as to how a SASH form had arrived in the prison without being previously noticed.
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about the designated recipient of SASH forms
Wider context from the report “(2) That the GEOAmey staff and Prison reception staff (including very experienced officers with both) had conflicting impressions of which Prison Officer (the one dealing with the warrants and Core record alternatively the one dealing with the property and the PER) was supposed to be the recipient of the SASH form. Training and refresher training as to their own procedures notwithstanding, there is a lack of appreciation by GEOAmey escort staff of the prison's reception procedures. There is a lack of awareness by prison staff of GEOAmey staff's ignorance of them. Alternatively, the prison reception staff develop the procedures without keeping GEOAmey staff informed. There is a tangible sense of one hand not knowing what the other is doing.
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure of reception procedures under foreseeable high-demand conditions
Wider context from the report “(1) That the circumstances on the 21st July 2014 at the reception included an inexperienced officer being on duty in conditions which were particularly onerous. It was described as the busiest he had ever seen by another more senior officer who was called away to deal with an incident, just at the time Mr Thomas was arriving in reception. Prison staff were adamant that another officer would have filled the gap left (although the identity of the substituting prison officer was not provided). These circumstances were clearly very demanding but they were not unforeseeable and may be repeated in future. When the procedures were “stress-tested” in the way they were on 21st July 2014, they failed so that a SASH form went unnoticed.
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure of GEOAmey and prison reception staff to understand and keep each other informed about interconnecting procedures
Wider context from the report “(2) That the GEOAmey staff and Prison reception staff (including very experienced officers with both) had conflicting impressions of which Prison Officer (the one dealing with the warrants and Core record alternatively the one dealing with the property and the PER) was supposed to be the recipient of the SASH form. Training and refresher training as to their own procedures notwithstanding, there is a lack of appreciation by GEOAmey escort staff of the prison's reception procedures. There is a lack of awareness by prison staff of GEOAmey staff's ignorance of them. Alternatively, the prison reception staff develop the procedures without keeping GEOAmey staff informed. There is a tangible sense of one hand not knowing what the other is doing.
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure of GEOAmey, prison and healthcare procedures to inter-operate safely
Wider context from the report “(5) That the above concerns go to the issue of the inter-operability of GEOAmey and prison and healthcare procedures, which is not yet addressed by any of the agencies. I note that the pilot scheme is designed to improve “information sharing” between agencies. I am concerned that this case provides a paradigm example of not just a failure in communication between agencies but a deeper failure in properly appreciating each other's procedures and potential weaknesses where they are supposed to inter-connect. Looked at holistically, the system is demonstrated to be dysfunctional in this case.
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Lack of a detailed, documented and tracked account of SASH form transmission
Wider context from the report “(3) That Prison reception staff in their evidence were adamant that a SASH form could never have been overlooked. However, prison staff at every level could provide no detailed, documented and tracked, account for how the SASH form had reached the prison records for Mr Thomas. There is an over reliance on the fidelity of the system, even when it has failed. No questions were asked at any stage on 21st July 2014, when it it passed from GEOAmey staff, to reception staff, to healthcare, or thereafter as to how a SASH form had arrived in the prison without being previously noticed.
” Open source report
11 Dec 2015 Margaret O’Brien · Prevention of Future Deaths report West London
View report summary
Concerns raised 2 Lack of specific, prescribed staff training on carrying out observations of residents View source Lack of specific, prescribed staff training on recording observations of residents 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
Margaret O’Brien · 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
Margaret O’Brien was discovered unresponsive in her bed at the care home where she resided, after showing signs of a cold the previous evening. The substantive concern was an absence of specific, prescribed staff training on carrying out and recording observations of residents.
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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Lack of specific, prescribed staff training on carrying out observations of residents
Wider context from the report “There appeared to be an absence of specific, prescribed training of staff on how to carry out and record observations of residents.
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Lack of specific, prescribed staff training on recording observations of residents
Wider context from the report “There appeared to be an absence of specific, prescribed training of staff on how to carry out and record observations of residents.
” Open source report
6 Sep 2015 Warren Martin Sampson · Prevention of Future Deaths report Essex
View report summary
Concerns raised 4 Lack of a process for following up non-attendance at Reception Healthcare first night screening View source Lack of a system ensuring that all officers are familiar with local directives and instructions View source Ad hoc attendance of representatives from all disciplines, especially Healthcare, at ACCT reviews View source Lack of written evidence of contributory input from other agencies in ACCT documentation View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Warren Martin Sampson · 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
Warren Martin Sampson had been remanded to HM Prison Chelmsford and was subject to an ACCT when he was found hanging in his cell. Concerns included inconsistent attendance and recording at ACCT reviews, no process for following up non-attendance at first-night healthcare screening, and no system ensuring officers were familiar with local directives and instructions.
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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Lack of a process for following up non-attendance at Reception Healthcare first night screening
Wider context from the report “(2) The lack of a process for following up non- attendance at the Reception Healthcare first night screening
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Lack of a system ensuring that all officers are familiar with local directives and instructions
Wider context from the report “(3) The lack of a system for ensuring that all officers are familiar with local directives and instructions
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Ad hoc attendance of representatives from all disciplines, especially Healthcare, at ACCT reviews
Wider context from the report “(1) The “ad hoc” attendance at ACCT reviews of representatives from all disciplines especially Healthcare . The lack of written evidence within the ACCT documentation of contributory input from other agencies such as Healthcare.
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Lack of written evidence of contributory input from other agencies in ACCT documentation
Wider context from the report “(1) The “ad hoc” attendance at ACCT reviews of representatives from all disciplines especially Healthcare. The lack of written evidence within the ACCT documentation of contributory input from other agencies such as Healthcare .
” Open source report
×
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 Undertake a second health screen within 72 hours of arrival, checking GP-record consent and recording refusals in SystmOne.
Verbatim wording from the response “The process now is that a Second Health Screen is undertaken within 72 hours of an inmate arriving at HMP Chelmsford and at that second health screen there would be a” Source location Response from Care UK
Open published response
×
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 Require daily email invitations to healthcare professionals for ACCT reviews and record their attendance or other input in ACCT documentation and SystmOne.
Verbatim wording from the response “It is the process now that discipline staff each day will email healthcare with the ACCT reviews they are intending to hold that day and invite the appropriate healthcare professional to input into the process, whether it be primary healthcare, mental health or a member of the substance misuse team. Attendance will be in person where possible but where a healthcare professional is unable to attend, the input of healthcare, for example, by telephone, must be recorded on the ACCT document and in SystmOne. This has been reaffirmed to healthcare staff.” Source location Response from Care UK
Open published response
Concerns raised 1 Inadequate staffing to supervise residents in communal areas during use 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
Alois Piska · 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
Alois Piska fell in the lounge of his nursing home on 29 May 2014, where no staff member was present, and sustained a non-survivable head injury. He died in hospital on 31 May 2014; the substantive concern was inadequate staffing to supervise residents in communal areas whenever they were in use.
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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Inadequate staffing to supervise residents in communal areas during use
Wider context from the report “There were inadequate numbers of staff at Harry Sotnick House to supervise residents in communal areas at all times when such areas are in use .
” Open source report
Concerns raised 4 Failure to give sufficient weight to mental health staff opinions in ACCT reviews View source Failure of ACCT review members to read the ACCT document before reviews View source Failure to ensure mental health staff attend relevant ACCT reviews View source Failure to share mental health information with other ACCT review members 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.
×
AI-generated summary
Geraldine Liege Kilborn · 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
Geraldine Liege Kilborn died in HMP Low Newton after repeatedly self-harming over the 22 days following her reception into the prison; the Jury could not determine her intention when she hung herself. The principal concerns were inadequate sharing and weighting of mental-health information during ACCT reviews, limited review of ACCT records by some panel members, and questions about review-panel membership and her location at the time of death.
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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure to give sufficient weight to mental health staff opinions in ACCT reviews
Wider context from the report “(1) There was a clear breakdown in sharing of information known to the mental health team with other members of some ACCT reviews. Evidence was given that there has been a change in service provision contracts since the death of the deceased and that mental health staff will now work weekends. Nevertheless, it is vital that in appropriate cases where a prisoner is on an ACCT and has had substantial mental health input that they both attend relevant ACCT reviews and their opinions are given sufficient weight . It is noted that mental health nurses never chair such ACCT reviews as case manager and in this case has revealed that even in attendance, their views might not be given sufficient weight .
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure of ACCT review members to read the ACCT document before reviews
Wider context from the report “(2) Witnesses confirmed that they often did not read much of the ACCT document prior to the ACCT review and relied more upon input of other attendees who might know the prisoner and opined their face to face assessment of the prisoner at the time. In this case, some ACCT review members had limited day to day experience of the deceased, whose temperament and presentation could change “like a light switch” and therefore face to face presentation could well be misleading. Thus in cases where the ACCT review was dealing with a particularly complex challenging prisoner and where an enhanced review was called for, it would seem appropriate for further consideration to be given to the question of review panel membership generally as well as, as above, mental health input in particular.
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure mental health staff attend relevant ACCT reviews
Wider context from the report “(1) There was a clear breakdown in sharing of information known to the mental health team with other members of some ACCT reviews. Evidence was given that there has been a change in service provision contracts since the death of the deceased and that mental health staff will now work weekends. Nevertheless, it is vital that in appropriate cases where a prisoner is on an ACCT and has had substantial mental health input that they both attend relevant ACCT reviews and their opinions are given sufficient weight. It is noted that mental health nurses never chair such ACCT reviews as case manager and in this case has revealed that even in attendance, their views might not be given sufficient weight.
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure to share mental health information with other ACCT review members
Wider context from the report “(1) There was a clear breakdown in sharing of information known to the mental health team with other members of some ACCT reviews. Evidence was given that there has been a change in service provision contracts since the death of the deceased and that mental health staff will now work weekends. Nevertheless, it is vital that in appropriate cases where a prisoner is on an ACCT and has had substantial mental health input that they both attend relevant ACCT reviews and their opinions are given sufficient weight. It is noted that mental health nurses never chair such ACCT reviews as case manager and in this case has revealed that even in attendance, their views might not be given sufficient weight.
” Open source report
Concerns raised 3 Failure to ensure accurate nurse and patient signatures for recorded medication dispensing View source Unauthorised appropriation, trading and stockpiling of patient medication View source Failure to ensure medication is handed directly to the intended patient View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Edward John Devlin · 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
Edward John Devlin was found dead in his cell at HMP Durham on 17 July 2011, having died from the effects of dihydrocodeine. The report raised concerns that medication, including potentially dangerous drugs, may have been slid under locked cell doors without confirming receipt or administration, creating risks of diversion, inaccurate medication records, stockpiling and potentially lethal overdose. It also found that his physical condition on the night before his death warranted medical assessment, but no such assessment was carried out.
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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure accurate nurse and patient signatures for recorded medication dispensing
Wider context from the report “(1) It was stated by a nurse that he had, while dispensing medication to Mr Devlin and other patient on F wing, slid strips of medication including dihydrocodeine under locked cell doors instead of handing it to the patient.
(2) He claimed this was his own common practice and was also common practice amongst nursing staff on F wing. This was in relation to potentially dangerous and/or tradable drugs like dihydrocodeine.
(3) If this were the case, no one would know whether a patient is taking the medication intended for him.
(4) Further, other healthcare professionals, assuming that medication was being taken by the patient, could base a future diagnosis upon this which would be potentially flawed.
(5) Assessing any other patient would become fraught with uncertainty as healthcare professionals could never know for certain what medication had been taken by him.
(6) The concomitant concern with 3, 4 and 5 above would be that the system whereby the dispensing of drugs is recorded by signatures of nurse and patient is either being ignored or subject to forgery .
(7) Further, no one would know whether somebody else was appropriating that patient’s medication.
(8) Depending on the type of medication, this may be traded within the establishment raising security concerns.
(9) The drugs could be stockpiled with a view to creating a potentially lethal overdose.
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Unauthorised appropriation, trading and stockpiling of patient medication
Wider context from the report “(1) It was stated by a nurse that he had, while dispensing medication to Mr Devlin and other patient on F wing, slid strips of medication including dihydrocodeine under locked cell doors instead of handing it to the patient.
(2) He claimed this was his own common practice and was also common practice amongst nursing staff on F wing. This was in relation to potentially dangerous and/or tradable drugs like dihydrocodeine.
(3) If this were the case, no one would know whether a patient is taking the medication intended for him.
(4) Further, other healthcare professionals, assuming that medication was being taken by the patient, could base a future diagnosis upon this which would be potentially flawed.
(5) Assessing any other patient would become fraught with uncertainty as healthcare professionals could never know for certain what medication had been taken by him.
(6) The concomitant concern with 3, 4 and 5 above would be that the system whereby the dispensing of drugs is recorded by signatures of nurse and patient is either being ignored or subject to forgery.
(7) Further, no one would know whether somebody else was appropriating that patient’s medication .
(8) Depending on the type of medication, this may be traded within the establishment raising security concerns .
(9) The drugs could be stockpiled with a view to creating a potentially lethal overdose .
” 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 Care UK; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure medication is handed directly to the intended patient
Wider context from the report “(1) It was stated by a nurse that he had, while dispensing medication to Mr Devlin and other patient on F wing, slid strips of medication including dihydrocodeine under locked cell doors instead of handing it to the patient .
(2) He claimed this was his own common practice and was also common practice amongst nursing staff on F wing. This was in relation to potentially dangerous and/or tradable drugs like dihydrocodeine.
(3) If this were the case, no one would know whether a patient is taking the medication intended for him .
(4) Further, other healthcare professionals, assuming that medication was being taken by the patient, could base a future diagnosis upon this which would be potentially flawed.
(5) Assessing any other patient would become fraught with uncertainty as healthcare professionals could never know for certain what medication had been taken by him.
(6) The concomitant concern with 3, 4 and 5 above would be that the system whereby the dispensing of drugs is recorded by signatures of nurse and patient is either being ignored or subject to forgery.
(7) Further, no one would know whether somebody else was appropriating that patient’s medication.
(8) Depending on the type of medication, this may be traded within the establishment raising security concerns.
(9) The drugs could be stockpiled with a view to creating a potentially lethal overdose.
” Open source report
×
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 Implement procedures to stop administering medication by sliding it under cell doors.
Verbatim wording from the response “the cell door. This was limited to night time medication rounds as the requirement to open a cell door when in patrol state requires a senior prison officer to be present and the working arrangements at the time did not always allow this. At the time this was highlighted as a clinical risk and not appropriate. Procedures were therefore put in place to ensure this practice ceased.” Source location Response from Care UK
Open published response
×
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 Develop and obtain clinical-governance approval for a formal policy governing NIP medication when staff cannot open a cell door.
Verbatim wording from the response “As part of investigation in the event of nursing staff not being able to administer NIP medication to a prisoner by opening the cell door, for example; the threat of violence from the individual or industrial action, I have identified that a formal policy should be developed and approved by Care UK clinical governance detailing the action required by nursing staff.” Source location Response from Care UK
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation There is no evidence that issuing in-possession medication under cell doors was common practice at HMP Durham.
Verbatim wording from the response “There is no evidence to suggest that putting IP medication under the cell doors is common practice in HMP Durham.” Source location Response from Care UK
Open published response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations