Downview Prison and Young Offender Institution

Justice · Prison or young offender institution

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First report 27 Oct 2014•Latest report 27 Oct 2014

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

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Concerns and recipient responses

Statements from Downview Prison and Young Offender Institution linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Surrey

    AI-generated summary

    Chrylin Angela Maria Norrell-Goldsmith · 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

    Chrylin Angela Maria Norrell-Goldsmith was found shortly before midnight on 26 July 2013, partially suspended by a ligature in her cell at HMP Downview. CPR and subsequent paramedic efforts were unsuccessful, and the jury concluded that she took her own life. The principal concerns included exposed pipework in the cell, multidisciplinary input at ACCT reviews, retention of primary source data in the Phoenix Programme, and recording significant medical events in records accessible to prison discipline staff.

    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 Downview Prison and Young Offender Institution; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to retain complete primary source data within the Phoenix Programme

    Wider context from the report

    “3. Retention of Primary Source Data within the Phoenix Programme Consideration should be given to ensuring that all primary source data (ie data provided by the prisoner to the therapist), should be kept either in hard copy format or by way of faithfully recoding all the detail contained therein on the prisoner’s System One 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 Downview Prison and Young Offender Institution; that does not assign responsibility.

    PFD Monitor interpretation

    Open and accessible ligature points within prisoner cells

    Wider context from the report

    “1. Open pipe work within the cell Whilst it may not be possible to remove all potential ligature points within a cell, removal of easily accessible and obvious ligature points may serve to reduce the risk of self harm and suicide to vulnerable prisoners. ”
    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 Downview Prison and Young Offender Institution; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to ensure multidisciplinary attendance or input at ACCT reviews

    Wider context from the report

    “2. Multi-Disciplinary Attendance / Input at ACCT Reviews Consideration should be given to ensuring that all staff, including prison staff, healthcare staff and In Reach staff understand the importance of requiring and providing multi-disciplinary attendance, or alternatively, multi-disciplinary input at all ACCT reviews. ”
    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 Downview Prison and Young Offender Institution; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to record significant medical events in prisoner non-medical records accessible to discipline staff

    Wider context from the report

    “4. Recording Significant Medical Events on a prisoner’s Non-medical Records Consideration should be given to ensuring that all members of healthcare and In Reach staff working within a prison environment record all significant medical events that may impact upon a prisoner’s risk assessment for self-harm or suicide in a place or manner that is readily accessible to the discipline staff at the prison, in addition to any entry made in respect thereof in the System One record. ”
    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

Data last updated 7 September 2026