20 Dec 2024 Haydar Jefferies · Prevention of Future Deaths report Surrey
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Concerns raised 11 Unavailability of medication for acute mental health symptoms overnight View source Unavailability of clinical mental health provision outside weekday office hours View source Failure to record prisoner welfare information provided in telephone calls View source Lack of a composite 24-hour information document for clinicians reviewing CSU prisoners View source Lack of custody staff training to recognise red flags of declining mental health View source Failure to verify completion of requested mental health referrals View source Failure to consolidate and disseminate prisoner concerns in daily briefing sheets View source Insufficient overnight staffing to take prisoners in mental health crisis to hospital View source Failure to provide necessary clinical knowledge for overnight mental health risk assessment View source Failure of the ACCT process to protect non-suicidal prisoners in acute mental health crisis View source Lack of a process to expedite face-to-face parole hearings for eligible IPP prisoners View source See 8 more concerns
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AI-generated summary
Haydar Jefferies · 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
Haydar Jefferies was detained at HMP Coldingley and developed severe depression and psychosis before self-ligaturing in his cell on 1 March 2023; he was resuscitated but died at hospital on 5 March 2023 from hypoxic brain injury and pneumonia. The principal concerns included failures to record and share risk-relevant information, refer him promptly to mental health services, provide an adequate mental health assessment and obtain appropriate clinical care and supervision during his acute deterioration.
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 Coldingley Prison; that does not assign responsibility.
PFD Monitor interpretation Unavailability of medication for acute mental health symptoms overnight
Wider context from the report “6. Outside of weekday office hours there is no clinical mental health provision. Overnight staffing levels are such that it is difficult for prisoners in mental health crisis to be taken to hospital. As a result:
a.) custodial staff take decisions about how to keep prisoners safe overnight without the necessary clinical knowledge to assess the risks presented by their mental health conditions.
b.) it is not possible for medication to be obtained to alleviate any acute mental health symptoms between 6.30 pm and 7am the following morning .
” 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 Coldingley Prison; that does not assign responsibility.
PFD Monitor interpretation Unavailability of clinical mental health provision outside weekday office hours
Wider context from the report “6. Outside of weekday office hours there is no clinical mental health provision . Overnight staffing levels are such that it is difficult for prisoners in mental health crisis to be taken to hospital. As a result:
a.) custodial staff take decisions about how to keep prisoners safe overnight without the necessary clinical knowledge to assess the risks presented by their mental health conditions.
b.) it is not possible for medication to be obtained to alleviate any acute mental health symptoms between 6.30 pm and 7am the following morning.
” 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 Coldingley Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to record prisoner welfare information provided in telephone calls
Wider context from the report “1. There is no system in place to ensure that information provided in telephone calls in relation to a prisoner’s welfare is recorded .
” 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 Coldingley Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of a composite 24-hour information document for clinicians reviewing CSU prisoners
Wider context from the report “3. There is no composite document for clinicians to review to see all relevant information recorded by custodial staff about a CSU prisoner for the proceeding 24 hour period .
” 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 Coldingley Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of custody staff training to recognise red flags of declining mental health
Wider context from the report “5. Custody staff are not trained in mental health presentations and are unable to recognise red flag indicators of declining mental health .
” 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 Coldingley Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to verify completion of requested mental health referrals
Wider context from the report “4. There is no system in place to check that referrals to the mental health teams requested by senior members of the prison staff have in fact been made .
” 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 Coldingley Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to consolidate and disseminate prisoner concerns in daily briefing sheets
Wider context from the report “2. Matters of concern in relation to prisoners are recorded across a number of different records and there is a risk that the information is missed and not disseminated in daily briefing sheets .
” 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 Coldingley Prison; that does not assign responsibility.
PFD Monitor interpretation Insufficient overnight staffing to take prisoners in mental health crisis to hospital
Wider context from the report “6. Outside of weekday office hours there is no clinical mental health provision. Overnight staffing levels are such that it is difficult for prisoners in mental health crisis to be taken to hospital . As a result:
a.) custodial staff take decisions about how to keep prisoners safe overnight without the necessary clinical knowledge to assess the risks presented by their mental health conditions.
b.) it is not possible for medication to be obtained to alleviate any acute mental health symptoms between 6.30 pm and 7am the following morning.
” 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 Coldingley Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to provide necessary clinical knowledge for overnight mental health risk assessment
Wider context from the report “6. Outside of weekday office hours there is no clinical mental health provision. Overnight staffing levels are such that it is difficult for prisoners in mental health crisis to be taken to hospital. As a result:
a.) custodial staff take decisions about how to keep prisoners safe overnight without the necessary clinical knowledge to assess the risks presented by their mental health conditions .
b.) it is not possible for medication to be obtained to alleviate any acute mental health symptoms between 6.30 pm and 7am the following morning.
” 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 Coldingley Prison; that does not assign responsibility.
PFD Monitor interpretation Failure of the ACCT process to protect non-suicidal prisoners in acute mental health crisis
Wider context from the report “7. The ACCT process is not designed nor effective to protect prisoners in acute mental health crisis who do not appear to be suicidal .
” 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 Coldingley Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of a process to expedite face-to-face parole hearings for eligible IPP prisoners
Wider context from the report “8. Imprisonment under an IPP is a recognised suicide risk. The delay in dealing with the IPP parole hearing exacerbated the risk. There is currently no process in place to expedite face to face parole hearings for IPP prisoners when allegations leading to their recall have been withdrawn and no criminal action is being considered .
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations