Recipient

Durham Prison

Pin Request correction

First report 22 Jul 2014•Latest report 21 Sep 2021

Recipient record

Reports, concerns and published responses

Justice · Prison or young offender institution. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports
4

Naming this recipient

Published responses
50%

Found for named reports

Concerns addressed
2

Across all linked responses

Stated actions
8

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.

50%published responses found
8stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

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

  1. County Durham and Darlington

    AI-generated summary

    CHARLIE BRIAN TODD · 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

    On 2 September 2019, Charlie Brian Todd, a prisoner at HMP Durham, was found hanging by a ligature in his cell in the Segregation & Care Unit and died despite resuscitation attempts. The report identifies concerns about staffing and supervision arrangements, including an incomplete record of hourly checks and no check of Mr Todd’s cell at 3pm, alongside the absence of a real-time system to alert staff to missed checks.

    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 Durham Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to complete SACU hourly prisoner checks consistently

    Wider context from the report

    “During the course of the inquest evidence was heard from a number of witnesses of the supervision and staffing arrangements within SACU. The overall position was that there was no supervising officer present on a day to day basis to ensure key tasks were always allocated or completed, and officers, including officers not posted to the SACU, but covering for a shift, were required to allocate various tasks between themselves on an ad hoc basis. On the 2nd September 2019 the document setting out which hourly checks had been undertaken in the SACU was incomplete. No check on Mr Todd’s cell took place at 3pm that day. Evidence was heard that staffing levels can vary, with officers being occupied on tasks which meant hourly checks could not always be completed. Whilst there is auditing of the hourly checks retrospectively, there is no ‘real time’ system which would alert officers and their supervisors to checks being incomplete for a prisoner/s as the record of checks are paper based and held in the SACU, as well there is no constant supervising officer present or other system there to ensure compliance. ”
    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 Durham Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of day-to-day supervision and structured allocation of key SACU tasks

    Wider context from the report

    “During the course of the inquest evidence was heard from a number of witnesses of the supervision and staffing arrangements within SACU. The overall position was that there was no supervising officer present on a day to day basis to ensure key tasks were always allocated or completed, and officers, including officers not posted to the SACU, but covering for a shift, were required to allocate various tasks between themselves on an ad hoc basis. On the 2nd September 2019 the document setting out which hourly checks had been undertaken in the SACU was incomplete. No check on Mr Todd’s cell took place at 3pm that day. Evidence was heard that staffing levels can vary, with officers being occupied on tasks which meant hourly checks could not always be completed. Whilst there is auditing of the hourly checks retrospectively, there is no ‘real time’ system which would alert officers and their supervisors to checks being incomplete for a prisoner/s as the record of checks are paper based and held in the SACU, as well there is no constant supervising officer present or other system there to ensure compliance. ”
    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 Durham Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of real-time detection of incomplete SACU prisoner checks

    Wider context from the report

    “During the course of the inquest evidence was heard from a number of witnesses of the supervision and staffing arrangements within SACU. The overall position was that there was no supervising officer present on a day to day basis to ensure key tasks were always allocated or completed, and officers, including officers not posted to the SACU, but covering for a shift, were required to allocate various tasks between themselves on an ad hoc basis. On the 2nd September 2019 the document setting out which hourly checks had been undertaken in the SACU was incomplete. No check on Mr Todd’s cell took place at 3pm that day. Evidence was heard that staffing levels can vary, with officers being occupied on tasks which meant hourly checks could not always be completed. Whilst there is auditing of the hourly checks retrospectively, there is no ‘real time’ system which would alert officers and their supervisors to checks being incomplete for a prisoner/s as the record of checks are paper based and held in the SACU, as well there is no constant supervising officer present or other system there to ensure compliance. ”
    Open source report

  2. County Durham and Darlington

    AI-generated summary

    Matthew David Hamilton · 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

    Matthew David Hamilton died after taking drugs on the day of his release from custody, following a period of abstinence, and was later treated in hospital for the toxic effects of morphine. The report identified concern that people released from custody may be unaware that reduced tolerance increases the risk that previously normal drug consumption may be fatal, and that the deceased had not received the relevant release information.

    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 Durham Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to ensure that people released from custody are aware of reduced drug tolerance and the fatal risk of pre-custody consumption levels

    Wider context from the report

    “On being released from custody, some users of heroin (and/or other drugs) are unaware of: (i) the fact or extent to which abstinence during imprisonment is likely to have reduced their tolerance to heroin (and/or other substances); and/or (ii) that consumption of those substances, at levels which may have been normal for them prior to their period in custody, may prove immediately fatal afterwards. ”
    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Update the drug and alcohol guidance pack with post-release harm-reduction information.

    Verbatim wording from the response

    “• The Drug and Alcohol Reduction Team (DART) have updated their guidance pack, which in future will be offered to all prisoners on their discharge from HMP Durham and not just to those who had elected to engage with DART while in custody. The guidance pack is also offered to those with the potential of release from court. I will be happy to supply a copy of the guidance pack should you wish to receive it.”

    Source location

    2019-0050-Response-by-HM-Prison-Probation-Service
    Page 1 · response
    Published 24 May 2019

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Deploy a trained prisoner DART Mentor to provide release-stage harm-reduction advice, including community support and drug-specific information.

    Verbatim wording from the response

    “• The DART team have a trained prisoner (DART Mentor) to offer additional harm reduction advice to prisoners at the point of release. This includes information on community based support services, as well drug specific, harm reduction information.”

    Source location

    2019-0050-Response-by-HM-Prison-Probation-Service
    Page 1 · response
    Published 24 May 2019

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Offer the updated guidance pack to all prisoners discharged from HMP Durham and people potentially released from court.

    Verbatim wording from the response

    “• The Drug and Alcohol Reduction Team (DART) have updated their guidance pack, which in future will be offered to all prisoners on their discharge from HMP Durham and not just to those who had elected to engage with DART while in custody. The guidance pack is also offered to those with the potential of release from court. I will be happy to supply a copy of the guidance pack should you wish to receive it.”

    Source location

    2019-0050-Response-by-HM-Prison-Probation-Service
    Page 1 · response
    Published 24 May 2019

    Open published response

  3. County Durham and Darlington

    AI-generated summary

    Derek Thomas · 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

    Derek Thomas died by suicide while in HMP Durham after arriving on remand and undergoing reception and first-night induction. Information suggesting suicidal intent was not adequately communicated or identified because of failures involving the SASH and PER forms across escort, prison reception and healthcare staff. The report raised concerns about procedures failing under demanding but foreseeable conditions, unclear inter-agency responsibilities, inadequate tracking of information, and poor interoperability between agencies.

    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 Durham Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to question unexplained SASH form transmission

    Wider context from the report

    “(3) That Prison reception staff in their evidence were adamant that a SASH form could never have been overlooked. However, prison staff at every level could provide no detailed, documented and tracked, account for how the SASH form had reached the prison records for Mr Thomas. There is an over reliance on the fidelity of the system, even when it has failed. No questions were asked at any stage on 21st July 2014, when it it passed from GEOAmey staff, to reception staff, to healthcare, or thereafter as to how a SASH form had arrived in the prison without being previously noticed. ”
    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 Durham Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of clarity about the designated recipient of SASH forms

    Wider context from the report

    “(2) That the GEOAmey staff and Prison reception staff (including very experienced officers with both) had conflicting impressions of which Prison Officer (the one dealing with the warrants and Core record alternatively the one dealing with the property and the PER) was supposed to be the recipient of the SASH form. Training and refresher training as to their own procedures notwithstanding, there is a lack of appreciation by GEOAmey escort staff of the prison's reception procedures. There is a lack of awareness by prison staff of GEOAmey staff's ignorance of them. Alternatively, the prison reception staff develop the procedures without keeping GEOAmey staff informed. There is a tangible sense of one hand not knowing what the other is doing. ”
    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 Durham Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of reception procedures under foreseeable high-demand conditions

    Wider context from the report

    “(1) That the circumstances on the 21st July 2014 at the reception included an inexperienced officer being on duty in conditions which were particularly onerous. It was described as the busiest he had ever seen by another more senior officer who was called away to deal with an incident, just at the time Mr Thomas was arriving in reception. Prison staff were adamant that another officer would have filled the gap left (although the identity of the substituting prison officer was not provided). These circumstances were clearly very demanding but they were not unforeseeable and may be repeated in future. When the procedures were “stress-tested” in the way they were on 21st July 2014, they failed so that a SASH form went unnoticed. ”
    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 Durham Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of GEOAmey and prison reception staff to understand and keep each other informed about interconnecting procedures

    Wider context from the report

    “(2) That the GEOAmey staff and Prison reception staff (including very experienced officers with both) had conflicting impressions of which Prison Officer (the one dealing with the warrants and Core record alternatively the one dealing with the property and the PER) was supposed to be the recipient of the SASH form. Training and refresher training as to their own procedures notwithstanding, there is a lack of appreciation by GEOAmey escort staff of the prison's reception procedures. There is a lack of awareness by prison staff of GEOAmey staff's ignorance of them. Alternatively, the prison reception staff develop the procedures without keeping GEOAmey staff informed. There is a tangible sense of one hand not knowing what the other is doing. ”
    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 Durham Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of GEOAmey, prison and healthcare procedures to inter-operate safely

    Wider context from the report

    “(5) That the above concerns go to the issue of the inter-operability of GEOAmey and prison and healthcare procedures, which is not yet addressed by any of the agencies. I note that the pilot scheme is designed to improve “information sharing” between agencies. I am concerned that this case provides a paradigm example of not just a failure in communication between agencies but a deeper failure in properly appreciating each other's procedures and potential weaknesses where they are supposed to inter-connect. Looked at holistically, the system is demonstrated to be dysfunctional in this case. ”
    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 Durham Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of a detailed, documented and tracked account of SASH form transmission

    Wider context from the report

    “(3) That Prison reception staff in their evidence were adamant that a SASH form could never have been overlooked. However, prison staff at every level could provide no detailed, documented and tracked, account for how the SASH form had reached the prison records for Mr Thomas. There is an over reliance on the fidelity of the system, even when it has failed. No questions were asked at any stage on 21st July 2014, when it it passed from GEOAmey staff, to reception staff, to healthcare, or thereafter as to how a SASH form had arrived in the prison without being previously noticed. ”
    Open source report

  4. County Durham and Darlington

    AI-generated summary

    Edward John Devlin · 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

    Edward John Devlin was found dead in his cell at HMP Durham on 17 July 2011, having died from the effects of dihydrocodeine. The report raised concerns that medication, including potentially dangerous drugs, may have been slid under locked cell doors without confirming receipt or administration, creating risks of diversion, inaccurate medication records, stockpiling and potentially lethal overdose. It also found that his physical condition on the night before his death warranted medical assessment, but no such assessment was carried out.

    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 Durham Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to ensure accurate nurse and patient signatures for recorded medication dispensing

    Wider context from the report

    “(1) It was stated by a nurse that he had, while dispensing medication to Mr Devlin and other patient on F wing, slid strips of medication including dihydrocodeine under locked cell doors instead of handing it to the patient. (2) He claimed this was his own common practice and was also common practice amongst nursing staff on F wing. This was in relation to potentially dangerous and/or tradable drugs like dihydrocodeine. (3) If this were the case, no one would know whether a patient is taking the medication intended for him. (4) Further, other healthcare professionals, assuming that medication was being taken by the patient, could base a future diagnosis upon this which would be potentially flawed. (5) Assessing any other patient would become fraught with uncertainty as healthcare professionals could never know for certain what medication had been taken by him. (6) The concomitant concern with 3, 4 and 5 above would be that the system whereby the dispensing of drugs is recorded by signatures of nurse and patient is either being ignored or subject to forgery. (7) Further, no one would know whether somebody else was appropriating that patient’s medication. (8) Depending on the type of medication, this may be traded within the establishment raising security concerns. (9) The drugs could be stockpiled with a view to creating a potentially lethal overdose. ”
    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 Durham Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Unauthorised appropriation, trading and stockpiling of patient medication

    Wider context from the report

    “(1) It was stated by a nurse that he had, while dispensing medication to Mr Devlin and other patient on F wing, slid strips of medication including dihydrocodeine under locked cell doors instead of handing it to the patient. (2) He claimed this was his own common practice and was also common practice amongst nursing staff on F wing. This was in relation to potentially dangerous and/or tradable drugs like dihydrocodeine. (3) If this were the case, no one would know whether a patient is taking the medication intended for him. (4) Further, other healthcare professionals, assuming that medication was being taken by the patient, could base a future diagnosis upon this which would be potentially flawed. (5) Assessing any other patient would become fraught with uncertainty as healthcare professionals could never know for certain what medication had been taken by him. (6) The concomitant concern with 3, 4 and 5 above would be that the system whereby the dispensing of drugs is recorded by signatures of nurse and patient is either being ignored or subject to forgery. (7) Further, no one would know whether somebody else was appropriating that patient’s medication. (8) Depending on the type of medication, this may be traded within the establishment raising security concerns. (9) The drugs could be stockpiled with a view to creating a potentially lethal overdose. ”
    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 Durham Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to ensure medication is handed directly to the intended patient

    Wider context from the report

    “(1) It was stated by a nurse that he had, while dispensing medication to Mr Devlin and other patient on F wing, slid strips of medication including dihydrocodeine under locked cell doors instead of handing it to the patient. (2) He claimed this was his own common practice and was also common practice amongst nursing staff on F wing. This was in relation to potentially dangerous and/or tradable drugs like dihydrocodeine. (3) If this were the case, no one would know whether a patient is taking the medication intended for him. (4) Further, other healthcare professionals, assuming that medication was being taken by the patient, could base a future diagnosis upon this which would be potentially flawed. (5) Assessing any other patient would become fraught with uncertainty as healthcare professionals could never know for certain what medication had been taken by him. (6) The concomitant concern with 3, 4 and 5 above would be that the system whereby the dispensing of drugs is recorded by signatures of nurse and patient is either being ignored or subject to forgery. (7) Further, no one would know whether somebody else was appropriating that patient’s medication. (8) Depending on the type of medication, this may be traded within the establishment raising security concerns. (9) The drugs could be stockpiled with a view to creating a potentially lethal overdose. ”
    Open source report
Back to top

Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

50%
50%All other recipients 58%
0%100%

How actions were described at the time

This respondent
88%12%
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