Coldingley Prison

Justice · Prison or young offender institution

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First report 20 Dec 2024•Latest report 20 Dec 2024

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports: 1
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

Concerns and recipient responses

Statements from Coldingley Prison linked to the concerns in each report. Select any concern, action or position to view the source wording.

20 Dec2024
Surrey
Concerns raised11
1. Unavailability of medication for acute mental health symptoms overnight
2. Unavailability of clinical mental health provision outside weekday office hours
3. Failure to record prisoner welfare information provided in telephone calls
1. Lack of a composite 24-hour information document for clinicians reviewing CSU prisoners
2. Lack of custody staff training to recognise red flags of declining mental health
3. Failure to verify completion of requested mental health referrals
4. Failure to consolidate and disseminate prisoner concerns in daily briefing sheets
5. Insufficient overnight staffing to take prisoners in mental health crisis to hospital
6. Failure to provide necessary clinical knowledge for overnight mental health risk assessment
7. Failure of the ACCT process to protect non-suicidal prisoners in acute mental health crisis
8. Lack of a process to expedite face-to-face parole hearings for eligible IPP prisoners
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
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

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised11

Unavailability of medication for acute mental health symptoms overnight

Unavailability of clinical mental health provision outside weekday office hours

Failure to record prisoner welfare information provided in telephone calls

Lack of a composite 24-hour information document for clinicians reviewing CSU prisoners

Lack of custody staff training to recognise red flags of declining mental health

Failure to verify completion of requested mental health referrals

Failure to consolidate and disseminate prisoner concerns in daily briefing sheets

Insufficient overnight staffing to take prisoners in mental health crisis to hospital

Failure to provide necessary clinical knowledge for overnight mental health risk assessment

Failure of the ACCT process to protect non-suicidal prisoners in acute mental health crisis

Lack of a process to expedite face-to-face parole hearings for eligible IPP prisoners