Concerns raised 2 Failure to recognise increased risk from persistently unusual behaviour View source Failure to use appropriate language when describing situations for risk assessment 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.
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AI-generated summary
Margaret Atkinson · 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
Margaret Atkinson, who had a long history of mental health illness and was in prison healthcare, was found unresponsive in her cell on 24 January 2016 after staff observed clothing around her neck and delayed entering the cell; she died in hospital on 2 February 2016. The jury found that staff should have entered earlier, and the report identified difficulties in describing such situations and assessing risk when unusual behaviour had become accepted as normal.
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 G4S Forensic & Medical Services (UK) Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise increased risk from persistently unusual behaviour
Wider context from the report “(1) The case revealed issues and difficulties about how situations were described and the choice of appropriate language with the corresponding difficulties resulting therefrom in assessing risk. Furthermore, as there was unusual behaviour over an extended period of time there was an acceptance of such behaviour as being normal and would not be considered as illustrative of increased risk unless there was a significant departure from that already unusual (or bizarre behaviour as it was described in evidence). HMP Low Newton have issued interim guidance to endeavour to address the matter and G4S likewise. A copy of the G4S guidance is attached. This appears good, I believe it needs to be shared throughout the prisoner state generally and not just in the North East cluster of prisons where G4S provides healthcare.
” 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 G4S Forensic & Medical Services (UK) Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure to use appropriate language when describing situations for risk assessment
Wider context from the report “(1) The case revealed issues and difficulties about how situations were described and the choice of appropriate language with the corresponding difficulties resulting therefrom in assessing risk . Furthermore, as there was unusual behaviour over an extended period of time there was an acceptance of such behaviour as being normal and would not be considered as illustrative of increased risk unless there was a significant departure from that already unusual (or bizarre behaviour as it was described in evidence). HMP Low Newton have issued interim guidance to endeavour to address the matter and G4S likewise. A copy of the G4S guidance is attached. This appears good, I believe it needs to be shared throughout the prisoner state generally and not just in the North East cluster of prisons where G4S provides healthcare.
” Open source report
Concerns raised 6 Failure to question unexplained SASH form transmission View source Lack of clarity about the designated recipient of SASH forms View source Failure of reception procedures under foreseeable high-demand conditions View source Failure of GEOAmey and prison reception staff to understand and keep each other informed about interconnecting procedures View source Failure of GEOAmey, prison and healthcare procedures to inter-operate safely View source Lack of a detailed, documented and tracked account of SASH form transmission View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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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 G4S Forensic & Medical Services (UK) Ltd; 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 G4S Forensic & Medical Services (UK) Ltd; 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 G4S Forensic & Medical Services (UK) Ltd; 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 G4S Forensic & Medical Services (UK) Ltd; 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 G4S Forensic & Medical Services (UK) Ltd; 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 G4S Forensic & Medical Services (UK) Ltd; 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
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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 Remind staff through meetings and briefings to ensure all paperwork accompanying each prisoner is transferred with them on arrival.
Verbatim wording from the response “The following further steps have been taken to address your concerns surrounding other issues arising at the inquest:-” Source location 2015-0502-Response-by-HMP-Durham
Open published response
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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 Instruct nursing staff to read and review all patient documents during reception screening.
Verbatim wording from the response “The following further steps have been taken to address your concerns surrounding other issues arising at the inquest:-” Source location 2015-0502-Response-by-HMP-Durham
Open published response
Concerns raised 3 Lack of clear ownership and responsibility for referrals to secondary care View source Failure to dispatch secondary care referral letters View source Failure of communication between general practitioners and podiatrists during concurrent patient care View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
James Bewick Graham · 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
James Bewick Graham, who had peripheral vascular disease and recurring problems with his left foot, was admitted to hospital after his condition deteriorated, underwent an amputation, and died on 2 November 2014. The report identified concerns about delayed referral to secondary care, poor communication between healthcare professionals, unclear responsibility for making the referral, and administrative failures that meant the referral was not dispatched.
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 G4S Forensic & Medical Services (UK) Ltd; that does not assign responsibility.
PFD Monitor interpretation Lack of clear ownership and responsibility for referrals to secondary care
Wider context from the report “(2) The GP who had most contact with the deceased in a 2 year period considered making a referral to secondary care on 17th October 2014 and instead of making the referral himself, passed the responsibility to make a referral to another GP (who worked one day per week) and who had previously sent a one page letter of referral to secondary care more than 2 years earlier. The GP gave evidence that he thought it appropriate for the original GP to make the referral as that GP had done the first one and was acquainted with the matter. The second GP gave evidence to say that she did not agree with this action because although, in principle, if there had been a recent referral it might have been appropriate for the original referring GP to make a second referral however after 2 years it was “stretching it a bit”. There was a lack of ownership and responsibility for the deceased’s care and making a referral to secondary care. There needs to be consideration given to the formulation of clear guidance as to which GP and in what circumstances has a responsibility for referrals to secondary care .
” 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 G4S Forensic & Medical Services (UK) Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure to dispatch secondary care referral letters
Wider context from the report “(3) The GP who agreed to make a referral to secondary care gave evidence that she had wrote out a letter of referral and handed it to a member of the administrative team for typing and gave verbal instructions that this needed to be dealt with quickly and that if there were any problems she was to be contacted. For an unknown reason the letter of referral was not dispatched. Some consideration has been given to this issue following the publication of the PPO report but in the light of the evidence given in court the thoroughness and robustness of that letter of direction, particularly bearing in mind there have been a number of changes to the providers of healthcare in the prison, should be considered.
” 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 G4S Forensic & Medical Services (UK) Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure of communication between general practitioners and podiatrists during concurrent patient care
Wider context from the report “(1) It is clear that on 16th October 2014 the deceased was seen by a general practitioner and a podiatrist at more or less the same time. The GP did not fully examine the deceased because he knew he was to see a podiatrist. The podiatrist discovered serious problems with the deceased’s foot and planned an urgent referral to the GP and did so by means of an electronic note which was seen by the GP who had seen the deceased immediately prior to the podiatrist, the day after, who then referred the matter to another GP to make a letter of referral and then because of administrative failures no referral to secondary care was made before the deceased died on 2nd November 2014. This shows a total lack of communication between the GP and the podiatrist who should have considered it appropriate to speak to one another whilst the deceased was still present in order to matters forward effectively.
” Open source report
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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 Require urgent secondary-care referrals to be discussed with the senior administrator and senior nurse.
Verbatim wording from the response “The following steps have been taken to address your concerns surrounding the manner in which referrals to secondary care are made and monitored:-” Source location James-Graham-Response
Open published response
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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 Inform the current GP provider of requirements for secondary-care referrals under the new contract.
Verbatim wording from the response “• Following the commencement of the new contract arrangements relating to the provision of healthcare services at HMP Frankland on 1 April 2015, the former head of healthcare at HMP Frankland is now employed by Spectrum Community Health CIC and therefore the current provider of GP Services at HMP Frankland is aware and informed of the requirements relating to referrals to secondary care.” Source location James-Graham-Response
Open published response
17 Jan 2014 Wayne Spencer Malcolm Broad · Prevention of Future Deaths report North London
View report summary
Concerns raised 3 Unavailability of specially trained nursing staff for hospital patients with substance misuse View source Unavailability of a dedicated substance misuse team in police custody suites View source Failure of SERCO handcuffing policy to align with ACPO guidance for seriously ill detainees View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Wayne Spencer Malcolm Broad · 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
Wayne Spencer Malcolm Broad was arrested while under the influence of alcohol and became unwell during transfer between police custody, court and hospital. He later developed delirium tremens, collapsed despite resuscitation and died after suffering a hypoxic injury. Concerns included the lack of a dedicated substance misuse team in police custody, the need for alignment of handcuffing procedures with guidance for seriously ill detainees, and the availability of specially trained nursing staff for patients with substance misuse.
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 G4S Forensic & Medical Services (UK) Ltd; that does not assign responsibility.
PFD Monitor interpretation Unavailability of specially trained nursing staff for hospital patients with substance misuse
Wider context from the report “(3) Specially trained nursing staff should be available at hospitals for dealing with patients with substance misuse .
” 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 G4S Forensic & Medical Services (UK) Ltd; that does not assign responsibility.
PFD Monitor interpretation Unavailability of a dedicated substance misuse team in police custody suites
Wider context from the report “(1) That was no dedicated substance misuse team available to look after Mr Broad when he was in the custody suite at Hatfield Police Station , as there would have been had Mr Broad been detained in prison.
” 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 G4S Forensic & Medical Services (UK) Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure of SERCO handcuffing policy to align with ACPO guidance for seriously ill detainees
Wider context from the report “(2) Police are required to make risk assessments and have requirements when dealing with the handcuffing of seriously ill detainees. There should be alignment with particular regard to those who are seriously ill and in general SERCO policy should come into alignment with ACPO guidance on the use of handcuffs .
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The current contract does not provide for dedicated substance misuse teams at police stations.
Verbatim wording from the response “G4S Forensic and Medical Service are responsible for the provision of medical services to Hertfordshire Police as defined in a specific contract written by Hertfordshire Police (“the Contract”), which does not at this time, provide for putting a dedicated substance misuse team into each of the police stations served by the Contract. Rather, the Contract requires us to provide medical staff to deal with a wide range of issues from the confirmation of death, intimate examinations of victims of sexual assault, advice on medical issues across a wide spectrum of circumstances and the provision of face to face clinical treatment of those detained in custody.” Source location 2014-0020R2_Redacted
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations