25 Feb 2014 Lee Terence Curran · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 6 Failure to fully investigate prisoners’ reported episodes of loss of consciousness View source Failure to conduct NICE-compliant investigations of loss of consciousness View source Failure to make accurate and evidentially grounded entries in prisoners’ medical notes View source Failure to conduct clinical investigations of prisoners experiencing loss of consciousness View source Failure to take full account of family history when clinically investigating prisoners with possible high cholesterol View source Lack of doctors’ awareness of NICE guidelines for transient loss of consciousness View source See 3 more concerns
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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
Lee Terence Curran · 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
Lee Terence Curran died on 3 May 2011 while in custody at Forest Bank Prison, with naturally occurring ischaemic heart disease identified as the prime cause of death. Before his death, he experienced multiple episodes of transient loss of consciousness that were not diagnosed, and concerns were raised that recommended investigations and follow-up were not provided. Further concerns included incomplete implementation of recommendations, potentially misleading medical-note entries, and inadequate awareness or application of relevant clinical guidelines.
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 Forest Bank Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to fully investigate prisoners’ reported episodes of loss of consciousness
Wider context from the report “(3) Evidence given at the Inquest also revealed a need for the training of Doctors working in prisons in that Doctors who provided general practice sessions at the prison (and in the community) gave evidence that they were unaware of the NICE Guidelines for Transient Loss of Consciousness Management in Adults and Young People despite such episodes being common in a prison environment. Additionally evidence was given by a Doctor that efforts were not made to fully investigate Lee Terence Curran’s episodes of loss of consciousness because, the Doctor explained, it was common for prisoners to claim to have suffered losses of consciousness as a form of drug seeking behaviour .
” 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 Forest Bank Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct NICE-compliant investigations of loss of consciousness
Wider context from the report “(1) The Prisons and Probation Ombudsman investigated Lee Terence Curran’s death. At the conclusion of that investigation certain recommendations were made, two of which were as follows:
a. “The Head of Healthcare should ensure that healthcare staff take full account of family history when arranging clinical investigations for prisoners who report, or are observed to have possible signs of high cholesterol or hypertension”.
b. “The Head of Healthcare should develop a protocol that is NICE compliant for investigating episodes of loss of consciousness and should ensure that staff conduct clinical investigations of prisoners who experience such episodes.”
Both of these recommendations were accepted. However the evidence given at the Inquest in relation to the implementation of recommendation a. was that all prisoners coming to Forest Bank Prison undertake the reception screening process and any prisoner with any identified, or any sign of, hypertension is referred to the hypertension clinic. A full account of the prisoner’s family history is then taken at that clinic. There was no evidence that any action had been taken to address that part of the Ombudsman’s recommendation that related to prisoners (such as Lee Terence Curran) who reported or showed signs of having high cholesterol.
Likewise with recommendation b. The evidence given at the Inquest with regard to the implementation of that recommendation was that any individual who had a loss of consciousness would be automatically referred to a Doctor. That action does not encompass the whole of the Ombudsman’s recommendation. Particularly it does not ensure that investigations of episodes of loss of consciousness are NICE compliant nor does it ensure that staff conduct clinical investigations of prisoners who experience such episodes. It should be remembered here that Doctors saw Lee Terence Curran on five occasions following episodes of loss of consciousness and the NICE guidelines were not followed at any time .
” 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 Forest Bank Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to make accurate and evidentially grounded entries in prisoners’ medical notes
Wider context from the report “(2) Evidence given at the Inquest revealed a potential need for the training of Prison staff as to the manner in which they make entries in prisoners’ medical notes. Expressly, incorrect, and potentially misleading, information had been entered in Lee Terence Curran’s medical notes concerning the episodes of loss of consciousness that he experienced. For example a nurse described one such episode as a “petit mal seizure,” whilst evidence at the Inquest made it clear that such could not have been the case. In addition those attending information did not make the basis upon which they were entering that information clear, that is they entered information that indicated that they had witnessed an event when they had not .
” 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 Forest Bank Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct clinical investigations of prisoners experiencing loss of consciousness
Wider context from the report “(1) The Prisons and Probation Ombudsman investigated Lee Terence Curran’s death. At the conclusion of that investigation certain recommendations were made, two of which were as follows:
a. “The Head of Healthcare should ensure that healthcare staff take full account of family history when arranging clinical investigations for prisoners who report, or are observed to have possible signs of high cholesterol or hypertension”.
b. “The Head of Healthcare should develop a protocol that is NICE compliant for investigating episodes of loss of consciousness and should ensure that staff conduct clinical investigations of prisoners who experience such episodes.”
Both of these recommendations were accepted. However the evidence given at the Inquest in relation to the implementation of recommendation a. was that all prisoners coming to Forest Bank Prison undertake the reception screening process and any prisoner with any identified, or any sign of, hypertension is referred to the hypertension clinic. A full account of the prisoner’s family history is then taken at that clinic. There was no evidence that any action had been taken to address that part of the Ombudsman’s recommendation that related to prisoners (such as Lee Terence Curran) who reported or showed signs of having high cholesterol.
Likewise with recommendation b. The evidence given at the Inquest with regard to the implementation of that recommendation was that any individual who had a loss of consciousness would be automatically referred to a Doctor. That action does not encompass the whole of the Ombudsman’s recommendation. Particularly it does not ensure that investigations of episodes of loss of consciousness are NICE compliant nor does it ensure that staff conduct clinical investigations of prisoners who experience such episodes . It should be remembered here that Doctors saw Lee Terence Curran on five occasions following episodes of loss of consciousness and the NICE guidelines were not followed at any time.
” 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 Forest Bank Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to take full account of family history when clinically investigating prisoners with possible high cholesterol
Wider context from the report “(1) The Prisons and Probation Ombudsman investigated Lee Terence Curran’s death. At the conclusion of that investigation certain recommendations were made, two of which were as follows:
a. “The Head of Healthcare should ensure that healthcare staff take full account of family history when arranging clinical investigations for prisoners who report, or are observed to have possible signs of high cholesterol or hypertension”.
b. “The Head of Healthcare should develop a protocol that is NICE compliant for investigating episodes of loss of consciousness and should ensure that staff conduct clinical investigations of prisoners who experience such episodes.”
Both of these recommendations were accepted. However the evidence given at the Inquest in relation to the implementation of recommendation a. was that all prisoners coming to Forest Bank Prison undertake the reception screening process and any prisoner with any identified, or any sign of, hypertension is referred to the hypertension clinic. A full account of the prisoner’s family history is then taken at that clinic. There was no evidence that any action had been taken to address that part of the Ombudsman’s recommendation that related to prisoners (such as Lee Terence Curran) who reported or showed signs of having high cholesterol.
Likewise with recommendation b. The evidence given at the Inquest with regard to the implementation of that recommendation was that any individual who had a loss of consciousness would be automatically referred to a Doctor. That action does not encompass the whole of the Ombudsman’s recommendation. Particularly it does not ensure that investigations of episodes of loss of consciousness are NICE compliant nor does it ensure that staff conduct clinical investigations of prisoners who experience such episodes. It should be remembered here that Doctors saw Lee Terence Curran on five occasions following episodes of loss of consciousness and the NICE guidelines were not followed at any time.
” 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 Forest Bank Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of doctors’ awareness of NICE guidelines for transient loss of consciousness
Wider context from the report “(3) Evidence given at the Inquest also revealed a need for the training of Doctors working in prisons in that Doctors who provided general practice sessions at the prison (and in the community) gave evidence that they were unaware of the NICE Guidelines for Transient Loss of Consciousness Management in Adults and Young People despite such episodes being common in a prison environment . Additionally evidence was given by a Doctor that efforts were not made to fully investigate Lee Terence Curran’s episodes of loss of consciousness because, the Doctor explained, it was common for prisoners to claim to have suffered losses of consciousness as a form of drug seeking behaviour.
” Open source report
14 Nov 2013 Anthony Brian Flynn · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 2 Failure to acknowledge and investigate clinicians’ concerns about prisoner treatment View source Lack of clinician awareness of powers to request changes to prisoners’ restraints View source
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
Anthony Brian Flynn · 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
Anthony Brian Flynn, who had diagnosed testicular cancer, was remanded into custody at Forest Bank Prison on 24 July 2012 and died there on 28 September 2012. The report raised concerns that he was handcuffed and chained during hospital appointments and examination, that a consultant’s concerns about the lack of compassion and difficulty conducting a sensitive examination were not acknowledged or investigated, and that training and procedures concerning restraints and clinicians’ powers needed consideration.
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 Forest Bank Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to acknowledge and investigate clinicians’ concerns about prisoner treatment
Wider context from the report “(3) On the 10th September 2012, ████████ a Consultant Clinical Oncologist at the Royal Preston Hospital who was treating Mr Flynn, wrote to HMP Forest Bank expressing concerns. She said “I was extremely concerned that there was an absolute lack of compassion demonstrated to what was a very sick man who was extremely distressed in the clinic. Unfortunately I felt that there was no really empathy in terms of the huge amount he had already received treatment for the significant side effects he has had and certainly conducting my examination of the abdomen and pelvis including the genitalia in a sensitive manner was extremely difficult.” Evidence given at the Inquest confirmed that Mr Flynn had been chained and handcuffed during the examination to which the Doctor refers.
(4) ████████ letter was received at HMP Forest Bank, but it was never acknowledged. No reply was sent, nor were the matters of concern described in the letter, especially that the Doctor had found it ‘extremely difficult’ to conduct the examination of Mr Flynn, ever investigated.
(5) Further evidence given at the Inquest revealed that:
a) When a prisoner is being escorted to hospital or other appointments escorting officers can, if they consider it appropriate, telephone the prison and seek permission to remove or lengthen the prisoner’s restraints.
b) Clinicians have the power to request that the action described in a) be taken, but most clinicians are unaware that they can do this.
(6) The evidence concluded that there was a need to consider the following:
a) The training of prison officers in relation to escorting prisoners, particularly during hospital visits.
b) Procedures for making clinicians, particularly hospital clinicians, aware of their powers in relation to prisoners attending for treatment.
” 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 Forest Bank Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of clinician awareness of powers to request changes to prisoners’ restraints
Wider context from the report “(3) On the 10th September 2012, ████████ a Consultant Clinical Oncologist at the Royal Preston Hospital who was treating Mr Flynn, wrote to HMP Forest Bank expressing concerns. She said “I was extremely concerned that there was an absolute lack of compassion demonstrated to what was a very sick man who was extremely distressed in the clinic. Unfortunately I felt that there was no really empathy in terms of the huge amount he had already received treatment for the significant side effects he has had and certainly conducting my examination of the abdomen and pelvis including the genitalia in a sensitive manner was extremely difficult.” Evidence given at the Inquest confirmed that Mr Flynn had been chained and handcuffed during the examination to which the Doctor refers.
(4) ████████ letter was received at HMP Forest Bank, but it was never acknowledged. No reply was sent, nor were the matters of concern described in the letter, especially that the Doctor had found it ‘extremely difficult’ to conduct the examination of Mr Flynn, ever investigated.
(5) Further evidence given at the Inquest revealed that:
a) When a prisoner is being escorted to hospital or other appointments escorting officers can, if they consider it appropriate, telephone the prison and seek permission to remove or lengthen the prisoner’s restraints.
b) Clinicians have the power to request that the action described in a) be taken, but most clinicians are unaware that they can do this.
(6) The evidence concluded that there was a need to consider the following:
a) The training of prison officers in relation to escorting prisoners, particularly during hospital visits.
b) Procedures for making clinicians, particularly hospital clinicians, aware of their powers in relation to prisoners attending for treatment.
” 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