25 Oct 2016 Richard Walsh · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 6 Failure to consider the whole person and reconcile or communicate missing and discordant information during proforma completion View source Failure of detained organisations to pass risk information consistently between one another View source Inadequate nurse assessment of fitness for segregation View source Lack of an agreed system for transferring health care information from police stations or courts to prisons View source Inadequate standard of Mental Health Act assessments View source Lack of clear responsibility for passing or seeking relevant information 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.
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AI-generated summary
Richard Walsh · 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
Richard Walsh was detained after being charged with attempted murder and, while experiencing delusions, refused food and drink with the stated intention of dying. He was transferred between HMP Highdown and HMP Belmarsh, where he was isolated in a single cell for 23½ hours a day and later died by hanging. The principal concerns were failures in communication and information-sharing between police, mental health, court and prison services, inadequate mental health assessment, and inadequate assessment of his fitness for segregation and suicide risk.
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 Dac Beachcroft LLP; that does not assign responsibility.
PFD Monitor interpretation Failure to consider the whole person and reconcile or communicate missing and discordant information during proforma completion
Wider context from the report “There appeared to be a focus by individuals on completing the proforma or questionnaire required by the system, by rote with either no time to consider the whole person , or no sense that it was their responsibility to consider missing or discordant information or to be proactive in communicating gaps in knowledge or concerns . From the evidence of a number of witnesses, the pattern of communication was not exceptional in this instance but reflected what usually happened.
” 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 Dac Beachcroft LLP; that does not assign responsibility.
PFD Monitor interpretation Failure of detained organisations to pass risk information consistently between one another
Wider context from the report “There was no agreed system for transfer of health care information from police station or court, or from either to prison. There was no functioning and consistent system of passing risk information from one detained organization to another. There was not agreement whether there just was a duty to pass the information or if it was not in possession, whether there was also one to ask for it and if so which individual bore that responsibility.
” 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 Dac Beachcroft LLP; that does not assign responsibility.
PFD Monitor interpretation Inadequate nurse assessment of fitness for segregation
Wider context from the report “3. That the inadequacy of the nurse assessment of fitness for segregation in HMP Highdown (see m) above) is a risk. ████████ was not ACCT trained and it appeared that he was unaware of PSI 1700. The inadequacy may reflect individual or wider weaknesses in assessment or choice of assessors that mean that prisoners go to segregation when they should be in the health care wing, or that they go without observation, when they should be on an ACCT and receive extra support.
” 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 Dac Beachcroft LLP; that does not assign responsibility.
PFD Monitor interpretation Lack of an agreed system for transferring health care information from police stations or courts to prisons
Wider context from the report “There was no agreed system for transfer of health care information from police station or court, or from either to prison. There was no functioning and consistent system of passing risk information from one detained organization to another. There was not agreement whether there just was a duty to pass the information or if it was not in possession, whether there was also one to ask for it and if so which individual bore that responsibility.
” 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 Dac Beachcroft LLP; that does not assign responsibility.
PFD Monitor interpretation Inadequate standard of Mental Health Act assessments
Wider context from the report “2. That the standard of Mental Health Act assessments by these individuals needs to be improved , and, given all three were in complete agreement, that also training and provision for MHA assessments in police stations more widely may need to be reviewed.
” 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 Dac Beachcroft LLP; that does not assign responsibility.
PFD Monitor interpretation Lack of clear responsibility for passing or seeking relevant information
Wider context from the report “There was no agreed system for transfer of health care information from police station or court, or from either to prison. There was no functioning and consistent system of passing risk information from one detained organization to another. There was not agreement whether there just was a duty to pass the information or if it was not in possession, whether there was also one to ask for it and if so which individual bore that responsibility.
” Open source report
21 May 2014 Mark Darren Bartholomew · Prevention of Future Deaths report Manchester North
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Concerns raised 6 Failure to retain and make essential observation documentation available View source Failure of communication in coordinating family notification of death View source Failure of observation records to specify and capture who and when observations are completed View source Lack of detailed guidance on access to and type of ligature cutters View source Failure to provide essential patient and emergency-equipment information to external emergency services View source Failure to ensure immediately available ligature cutters in the secure clinic 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
Mark Darren Bartholomew · 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 Darren Bartholomew, who had a longstanding diagnosis of paranoid schizophrenia and was detained in hospital after transfer from prison, died by hanging on 25 July 2013 during a routine observation check. Concerns included an inadequate response to emergency services, the absence of the ligature cutter needed to release him promptly, and insufficient detail in observation records.
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 Dac Beachcroft LLP; that does not assign responsibility.
PFD Monitor interpretation Failure to retain and make essential observation documentation available
Wider context from the report “1. Notwithstanding the Trust’s policy entitled ’2999 Procedure’ the purpose of which is to advise staff of process during a psychiatric emergency, it was clear that the response to external emergency services was inadequate. More particularly:-
• The informant was unable to provide the emergency controller with either the name or age of the patient; whether he was still breathing; and whether a defibrillator was available.
• Essential documentation (the observation record for the relevant 24 hour period) was mislaid and not available for the Inquest.
• Originally, a joint visit by both Police and Trust staff was arranged for the purpose of relaying news of the deceased’s death to the family. By reason of a lack of communication, the family were notified following an attendance by uniformed officers whereupon the deceased’s Mother telephoned the Trust.
” 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 Dac Beachcroft LLP; that does not assign responsibility.
PFD Monitor interpretation Failure of communication in coordinating family notification of death
Wider context from the report “1. Notwithstanding the Trust’s policy entitled ’2999 Procedure’ the purpose of which is to advise staff of process during a psychiatric emergency, it was clear that the response to external emergency services was inadequate. More particularly:-
• The informant was unable to provide the emergency controller with either the name or age of the patient; whether he was still breathing; and whether a defibrillator was available.
• Essential documentation (the observation record for the relevant 24 hour period) was mislaid and not available for the Inquest.
• Originally, a joint visit by both Police and Trust staff was arranged for the purpose of relaying news of the deceased’s death to the family. By reason of a lack of communication, the family were notified following an attendance by uniformed officers whereupon the deceased’s Mother telephoned the Trust.
” 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 Dac Beachcroft LLP; that does not assign responsibility.
PFD Monitor interpretation Failure of observation records to specify and capture who and when observations are completed
Wider context from the report “3. The Trust has a documented Observation Policy. Whilst the Policy requires records to be contemporaneously recorded, it does not specify how this is to be achieved . The actual observation sheet apparently in use at present indicates a poor level of detail as to who and when it is completed and in its present format would not withstand a rigorous audit .
” 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 Dac Beachcroft LLP; that does not assign responsibility.
PFD Monitor interpretation Lack of detailed guidance on access to and type of ligature cutters
Wider context from the report “2. Ligature Cutters – The Consultant Forensic Pathologist, ████████ confirmed in evidence that time was very much of the essence. Specifically he stated ‘following application, pressure through the ligature, and unconsciousness may ensue within a few seconds with death within minutes’
The registered nurse in charge of the ward ran to the scene, but then had to retrieve the ligature cutters which should have been in the front pocket of a bag attached to a hook on the wall in the secure clinic. The ligature cutter had in fact been used following an incident a week earlier and had not been returned. Despite a regime of daily checking, the absence had gone unnoticed. The Nurse-in-Charge immediately retrieved the ward scissors from a locked drawer and the ligature was subsequently released albeit approximately 2 minutes later. To the credit of the Trust, the practice of daily checks for equipment has now been superseded by a check at the commencement of each shift.
Although alerted to Department of Health guidance from 2007, I can find no detailed guidance with regard to either access to or the type of ligature cutter to be used. Evidence was given to the Inquest by the Senior Investigating Officer of Greater Manchester Police who made reference to the use of an implement carried in a pouch by Custody Sergeants within the Custody Office of designated Police Stations. The Senior Investigating Officer was not aware of any untoward incident arising from the use of such an implement which according to the Officer cannot be used to inflict harm on a third person. If the Security Nurse who had initially attended had been carrying such an implement, the ligature would have been released within a matter of seconds rather than minutes.
” 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 Dac Beachcroft LLP; that does not assign responsibility.
PFD Monitor interpretation Failure to provide essential patient and emergency-equipment information to external emergency services
Wider context from the report “1. Notwithstanding the Trust’s policy entitled ’2999 Procedure’ the purpose of which is to advise staff of process during a psychiatric emergency, it was clear that the response to external emergency services was inadequate . More particularly:-
• The informant was unable to provide the emergency controller with either the name or age of the patient; whether he was still breathing; and whether a defibrillator was available.
• Essential documentation (the observation record for the relevant 24 hour period) was mislaid and not available for the Inquest.
• Originally, a joint visit by both Police and Trust staff was arranged for the purpose of relaying news of the deceased’s death to the family. By reason of a lack of communication, the family were notified following an attendance by uniformed officers whereupon the deceased’s Mother telephoned the Trust.
” 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 Dac Beachcroft LLP; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure immediately available ligature cutters in the secure clinic
Wider context from the report “2. Ligature Cutters – The Consultant Forensic Pathologist, ████████ confirmed in evidence that time was very much of the essence. Specifically he stated ‘following application, pressure through the ligature, and unconsciousness may ensue within a few seconds with death within minutes’
The registered nurse in charge of the ward ran to the scene, but then had to retrieve the ligature cutters which should have been in the front pocket of a bag attached to a hook on the wall in the secure clinic . The ligature cutter had in fact been used following an incident a week earlier and had not been returned. Despite a regime of daily checking, the absence had gone unnoticed. The Nurse-in-Charge immediately retrieved the ward scissors from a locked drawer and the ligature was subsequently released albeit approximately 2 minutes later . To the credit of the Trust, the practice of daily checks for equipment has now been superseded by a check at the commencement of each shift.
Although alerted to Department of Health guidance from 2007, I can find no detailed guidance with regard to either access to or the type of ligature cutter to be used. Evidence was given to the Inquest by the Senior Investigating Officer of Greater Manchester Police who made reference to the use of an implement carried in a pouch by Custody Sergeants within the Custody Office of designated Police Stations. The Senior Investigating Officer was not aware of any untoward incident arising from the use of such an implement which according to the Officer cannot be used to inflict harm on a third person. If the Security Nurse who had initially attended had been carrying such an implement, the ligature would have been released within a matter of seconds rather than minutes.
” 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