Recipient

CRG Medical Services

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First report 24 Sep 2020•Latest report 13 Nov 2023

Recipient record

Reports, concerns and published responses

Health and care · Independent healthcare provider. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports
2

Naming this recipient

Published responses
100%

Found for named reports

Concerns addressed
1

Across all linked responses

Stated actions
12

Described in responses

Reports over time

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

100%published responses found
12stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

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

  1. Essex

    AI-generated summary

    John Paul Pace · 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 Paul Pace was serving a prison sentence at HMP Chelmsford and was receiving methadone as part of a drug detoxification programme. He stopped taking methadone before completing the programme and was found unresponsive at the prison on 22 July 2020; the post-mortem examination concluded that the likely medical cause of death was synthetic cannabinoid misuse. The principal concern was that a new discharge pathway for prisoners who stopped or completed methadone detoxification had not been documented in policies or procedures, creating a risk that monitoring and support would not be provided consistently.

    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 CRG Medical Services; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to document and embed the drug detoxification discharge pathway in operating procedures

    Wider context from the report

    “One of the material issues in evidence was about changes in the discharge pathway for prisoners on methadone detoxification as well as those who decided to stop the detoxification programme before completion. CRG identified the need for this change in their Root Cause Analysis review and their live witnesses provided evidence that this new process is now being followed. Forward Trust provided evidence that this is the new process now embedded in their operating procedure. However, no documentary evidence of this new drug detoxification discharge pathway seems to exist, no protocols, no written procedures, no policy, no addendum to existing policies and procedures. It is my concern that this new discharge pathway aimed at providing monitoring and support to prisoners who stop or complete the programme whilst in prison, has not been embedded in your organisations’ operating procedure and as such, there is a risk to prisoners in the future as compliance with the new discharge pathway and consistency of operations cannot be ensured. ”
    Open source report

  2. Essex

    AI-generated summary

    Zak Miles Joe Walter Paul Farmer · 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

    Zak Miles Joe Walter Paul Farmer, a 23-year-old man, died on 21 July 2019 after being found hanging. Concerns included a lack of clarity about the meaning of “urgent” referrals to the Access and Assessment Team and shortcomings in guidance for community mental health service users disengaging from prescribed treatment plans.

    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 CRG Medical Services; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of defined steps when a patient cannot be contacted

    Wider context from the report

    “1. There appeared to be a lack of clarity over the meaning of the word “urgent” when a referral is made to the Access and Assessment Team and what steps will be taken if a patient cannot be contacted. ”
    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 CRG Medical Services; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of clarity about the meaning of “urgent” referrals to the Access and Assessment Team

    Wider context from the report

    “1. There appeared to be a lack of clarity over the meaning of the word “urgent” when a referral is made to the Access and Assessment Team and what steps will be taken if a patient cannot be contacted. ”
    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 CRG Medical Services; that does not assign responsibility.

    PFD Monitor interpretation

    Inadequacy of clinical guidelines for community mental health service users disengaging or non concordant with prescribed treatment plans

    Wider context from the report

    “2. The trust document Clinical Guidelines for Community Mental Health Service Users disengaging or non concordant with current prescribed treatment plans was found lacking and requires perfecting. ”
    Open source report
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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

100%
100%All other recipients 58%
0%100%

How actions were described at the time

This respondent
58%8%33%
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

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