13 Mar 2024 Jacob Michael Nicholas BILLINGTON · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 5 Failure to record prisoners’ GP and CMHT details in an easily accessible format View source Failure to establish effective information sharing for prison discharge coordination View source Lack of cross-agency provisions and guidance for release planning of high-risk prisoners with mental health difficulties View source Unclear responsibilities and case remit for the prison discharge coordinator role View source Failure to coordinate interagency release management and share critical information View source See 2 more concerns
Responses linked to these concerns
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AI-generated summary
Jacob Michael Nicholas BILLINGTON · 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
Jacob Michael Nicholas Billington was unlawfully killed when he was stabbed in the neck during a night out in Birmingham on 6 September 2020. The concerns included inadequate coordination and information-sharing between agencies during the release of a high-risk prisoner with serious mental health difficulties, and a lack of clear cross-agency guidance and understanding of responsibilities.
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; that does not assign responsibility.
PFD Monitor interpretation Failure to record prisoners’ GP and CMHT details in an easily accessible format
Wider context from the report “2. Sysmone Details of the perpetrators GP and local CMHT were not recorded in an easily accessible format. The format in which key information is recorded has now been amended at HMP Swansea to ensure the prisoner’s GP details and their CMHT’s details (if a person is an existing patient under a CMHT) are highlighted on a front screen/page. I was informed that this change in information management and presentation within Sysmone is unique to HMP Swansea and is not the practice in other prisons. I am concerned that there remains a risk that staff treating patients in prison may not have easy access to (and so overlook) this key information.
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure to establish effective information sharing for prison discharge coordination
Wider context from the report “4. West Midlands MAPPA has a prison discharge coordinator role. It was clear from the evidence at the inquest that this role was not fully understood by other agencies and what information needed to be shared was not clear. The new policy drafted by BSMHT remained confused as to which cases were to fall within the responsibility of the prison discharge coordinator role. There remains a risk of further deaths as the role is not properly understood and information sharing is not effective.
” 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; that does not assign responsibility.
PFD Monitor interpretation Lack of cross-agency provisions and guidance for release planning of high-risk prisoners with mental health difficulties
Wider context from the report “3. Cross agency guidance regarding release of high risk prisoners with mental health difficulties at their sentence end date. There are no provisions available nor any cross agency guidance in place for when a high-risk prisoner is released at sentence end date to ensure that there is adequate release planning and maximum support in the community.
” 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; that does not assign responsibility.
PFD Monitor interpretation Unclear responsibilities and case remit for the prison discharge coordinator role
Wider context from the report “4. West Midlands MAPPA has a prison discharge coordinator role. It was clear from the evidence at the inquest that this role was not fully understood by other agencies and what information needed to be shared was not clear. The new policy drafted by BSMHT remained confused as to which cases were to fall within the responsibility of the prison discharge coordinator role. There remains a risk of further deaths as the role is not properly understood and information sharing is not effective.
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure to coordinate interagency release management and share critical information
Wider context from the report “1. Management of release and lack of interagency working. The management of the perpetrators release was not coordinated and there was inadequate communication between relevant agencies. In effect agencies worked in silos. Critical information is not being shared and agencies work in different IT systems meaning there is no one place where information is collated and hence a comprehensive account of matters known to each agency is not easily available to those professionals who may need to know a high risk prisoner’s whereabouts on release. This concern was reinforced by evidence heard during the inquest that changes made since Jacob's death did not include the resettlement information being given to Mental Health In reach teams in the prison. The failure to share information leads to a concern of future deaths as high risk seriously unwell prisoners may be released without key agencies knowing where they are meaning any are not traced and treated assertively in the community.
” 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 Hold monthly strategy meetings monitoring first-night accommodation and whether released prisoners’ whereabouts are known to community services.
Verbatim wording from the response “• Monthly strategy meetings at the prison show consistently high (c 90%) levels of prisoners released from custody are housed on the first night of their release, so that their whereabouts immediately post release is known to relevant community services.” Source location Response from G4S Care Justice Services (UK) Ltd
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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 offender managers to notify Community Offender Managers about sentence-end releases involving no fixed abode and provide release-destination information.
Verbatim wording from the response “• Whilst Community Offender Managers have responsibility for the coordination of release planning, notice was given by email to all offender managers within HMP & YOI Parc that they must notify the relevant Community Offender Manager when a prisoner is being released at sentence end date and will be of no fixed abode. When doing so, they must provide any information relating to a prisoner’s intentions in terms of where they are going on the day of release. This will assist the Community Offender Manager to effectively manage the prisoner’s release, and to coordinate and link in with other external agencies believed by the Community Offender Manager to be relevant to coordinate interagency working.” Source location Response from G4S Care Justice Services (UK) Ltd
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 Introduce resettlement-services drop-in sessions for prisoners approaching release.
Verbatim wording from the response “• Resettlement services drop-in sessions have been introduced and approved laptops have been received from HMPPS to roll out remote sessions under resettlement activities, to encourage engagement with resettlement services by prisoners approaching release and to provide opportunities to gather further information.” Source location Response from G4S Care Justice Services (UK) Ltd
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 Roll out remote resettlement-services sessions using approved laptops.
Verbatim wording from the response “• Resettlement services drop-in sessions have been introduced and approved laptops have been received from HMPPS to roll out remote sessions under resettlement activities, to encourage engagement with resettlement services by prisoners approaching release and to provide opportunities to gather further information.” Source location Response from G4S Care Justice Services (UK) Ltd
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 Continue streamlining internal data recording so information is shared through the national prisons IT system, DPS.
Verbatim wording from the response “The HMPPS primary national electronic records system used in all prisons in England and Wales is DPS (formerly PNOMIS). Other agencies involved in OMU and resettlement utilise other records systems, including NDel ius (the Probation Service), SystmOne/other electronic clinical records systems, and other records systems used by third party providers. G4S has no power to implement changes to streamline IT systems used by HMPPS, the NHS and/or other third party providers. Other interested persons may be better able to assist HM Senior Coroner in relation to this issue. G4S will, however, continue to streamline its own data recording, to ensure as much information as possible is shared through the primary national prisons IT system, DPS. G4S has very limited access to NDel ius, but information on this system is regularly accessible to Probation Service” Source location Response from G4S Care Justice Services (UK) Ltd
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 Record travel-warrant destinations and email them to the OMU group for communication to relevant offender managers and agencies.
Verbatim wording from the response “• At HMP & YOI Parc, a member of the cashiers team issues a travel warrant for each prisoner shortly before they are released from custody. The cashier previously recorded on CMS, the prison’s central electronic messaging system, the fact that a travel warrant had been issued. The cashier now records where the travel warrant has been issued to, and, in addition, sends an email to a new OMU email group, which includes healthcare admin and the Heads of Offender Management, to indicate that a travel warrant has been issued with details of where the travel warrant has been issued to. This email is automatically received by all offender managers within OMU. This information is then communicated to the Community Offender Manager and any other individuals/agencies involved with the prisoner.” Source location Response from G4S Care Justice Services (UK) Ltd
Open published response
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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 Concerns about SystmOne, cross-agency release guidance and the MAPPA discharge coordinator fall outside G4S’s power to address.
Verbatim wording from the response “G4S confines its response to the first concern identified relating to the management of release from prison and interagency working.” Source location Response from G4S Care Justice Services (UK) Ltd
Open published response
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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 Other interested persons addressed by the report are better placed to consider concerns 2, 3 and 4 and determine any response.
Verbatim wording from the response “G4S has no power to take action regarding concerns 2, 3 and 4, and, therefore, is not in a position to assist HM Senior Coroner with regard to these concerns. Other interested persons to whom the Regulation 28 report has been addressed are better able to consider the concerns raised, take action and/or explain why no action is proposed.” Source location Response from G4S Care Justice Services (UK) Ltd
Open published response
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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 G4S cannot implement changes to streamline IT systems used by HMPPS, the NHS and third-party providers.
Verbatim wording from the response “The HMPPS primary national electronic records system used in all prisons in England and Wales is DPS (formerly PNOMIS). Other agencies involved in OMU and resettlement utilise other records systems, including NDel ius (the Probation Service), SystmOne/other electronic clinical records systems, and other records systems used by third party providers. G4S has no power to implement changes to streamline IT systems used by HMPPS, the NHS and/or other third party providers. Other interested persons may be better able to assist HM Senior Coroner in relation to this issue. G4S will, however, continue to streamline its own data recording, to ensure as much information as possible is shared through the primary national prisons IT system, DPS. G4S has very limited access to NDel ius, but information on this system is regularly accessible to Probation Service” Source location Response from G4S Care Justice Services (UK) Ltd
Open published response
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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 G4S cannot influence release management or interagency working at private prisons operated by other providers or HMPPS.
Verbatim wording from the response “In addition, G4S has no power to influence the management of release of prisoners from, and/or to ensure interagency working at, private prisons operated by other providers or HMPPS operations.” Source location Response from G4S Care Justice Services (UK) Ltd
Open published response
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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 HMPPS is responsible for providing and operating resettlement services, which are delivered by HMPPS-commissioned external providers.
Verbatim wording from the response “HMPPS has responsibility for provision and operation of resettlement services. Such resettlement services at HMP & YOI Parc are commissioned by HMPPS from external providers who are based within the prison to facilitate resettlement services for prisoners approaching release from custody. G4S is not party to the procurement or placement of resettlement services within HMP & YOI Parc or the direct delivery of these services. G4S’ focus is on ensuring alignment and integration with third party service providers to ensure effective interagency working.” Source location Response from G4S Care Justice Services (UK) Ltd
Open published response
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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 Issues concerning information sharing on NDelius should be addressed to HMPPS.
Verbatim wording from the response “The HMPPS primary national electronic records system used in all prisons in England and Wales is DPS (formerly PNOMIS). Other agencies involved in OMU and resettlement utilise other records systems, including NDel ius (the Probation Service), SystmOne/other electronic clinical records systems, and other records systems used by third party providers. G4S has no power to implement changes to streamline IT systems used by HMPPS, the NHS and/or other third party providers. Other interested persons may be better able to assist HM Senior Coroner in relation to this issue. G4S will, however, continue to streamline its own data recording, to ensure as much information as possible is shared through the primary national prisons IT system, DPS. G4S has very limited access to NDel ius, but information on this system is regularly accessible to Probation Service” Source location Response from G4S Care Justice Services (UK) Ltd
Open published response
23 Jun 2019 Marcus William George McGuire · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 2 Failure of managers to maintain or communicate accurate information about ACCT improvements View source Failure to provide an embedded single case manager for each ACCT 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
Marcus William George McGuire · 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
Marcus William George McGuire died at HMP Birmingham on 24 April 2018 after being found in his cell with a ligature around his neck. The inquest concluded that his suicide was possibly contributed to by failures to carry out a mental health assessment, respond to missed anti-psychotic medication, involve mental health services in the ACCT process, assess his risk using all relevant information, and properly manage the ACCT.
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; that does not assign responsibility.
PFD Monitor interpretation Failure of managers to maintain or communicate accurate information about ACCT improvements
Wider context from the report “1. Many of the deficiencies in Mr. McGuire’s ACCT plan, such as the absence of a properly completed care plan, the failure to involve the mental health team, failure to consider all relevant and available information and failure to carry out an effective post-closure review, were attributable to the absence of an identified case manager which resulted in different members of staff chairing his case reviews and no-one taking responsibility to follow up on action points.
2. At the time of Mr. McGuire’s death it was not uncommon for ACCTs not to have an identified case manager.
3. Evidence was given at inquest that there has been an increase in the number of trained case managers to enable all ACCTs to have a designated single case manager who will remain the case manager for the life of the ACCT so far as reasonably possible and where a change is required, there is a formal hand-over process.
4. Following completion of the evidence, the Report on an independent review of progress at HMP Birmingham by H. M. Chief Inspector of Prisons based on an inspection of the 7th to 9th May 2019 was brought to my attention. Paragraph 2.27 of the report provides:
“The quality of ACCT casework was not yet good enough. In response to our concern at the last inspection, managers had sought to deliver single case management and provide prisoners in crisis with activities. This ambition has not yet been realised. None of the eight cases we checked had a single case manager...”
5. I am also aware that in a letter dated the 11th June 2019, ████████, Head of Custodial Contracts responded to the Report on the review of progress on behalf of H. M. Prison & Probation Service. In the response it is recognised that “we need to do more to embed single case management”.
6. I am concerned that I was given the impression that single case management is embedded at HMP Birmingham: if I had been aware that it was not, I would have sought additional evidence on why, what needed to be done to “embed” single case management and how it is intended to achieve it.
7. I am concerned that the disparity between the evidence given to me and the findings upon inspection 6 weeks earlier indicates that Managers at HMP Birmingham are either not aware of or not conveying the reality of the extent to which improvements in the ACCT process have been achieved.
8. The absence of an embedded system of single case management will put lives at risk as compliance with the ACCT process cannot be assured.
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure to provide an embedded single case manager for each ACCT
Wider context from the report “1. Many of the deficiencies in Mr. McGuire’s ACCT plan, such as the absence of a properly completed care plan, the failure to involve the mental health team, failure to consider all relevant and available information and failure to carry out an effective post-closure review, were attributable to the absence of an identified case manager which resulted in different members of staff chairing his case reviews and no-one taking responsibility to follow up on action points .
2. At the time of Mr. McGuire’s death it was not uncommon for ACCTs not to have an identified case manager .
3. Evidence was given at inquest that there has been an increase in the number of trained case managers to enable all ACCTs to have a designated single case manager who will remain the case manager for the life of the ACCT so far as reasonably possible and where a change is required, there is a formal hand-over process.
4. Following completion of the evidence, the Report on an independent review of progress at HMP Birmingham by H. M. Chief Inspector of Prisons based on an inspection of the 7th to 9th May 2019 was brought to my attention. Paragraph 2.27 of the report provides:
“The quality of ACCT casework was not yet good enough. In response to our concern at the last inspection, managers had sought to deliver single case management and provide prisoners in crisis with activities. This ambition has not yet been realised. None of the eight cases we checked had a single case manager... ”
5. I am also aware that in a letter dated the 11th June 2019, ████████, Head of Custodial Contracts responded to the Report on the review of progress on behalf of H. M. Prison & Probation Service. In the response it is recognised that “we need to do more to embed single case management ”.
6. I am concerned that I was given the impression that single case management is embedded at HMP Birmingham: if I had been aware that it was not, I would have sought additional evidence on why, what needed to be done to “embed” single case management and how it is intended to achieve it.
7. I am concerned that the disparity between the evidence given to me and the findings upon inspection 6 weeks earlier indicates that Managers at HMP Birmingham are either not aware of or not conveying the reality of the extent to which improvements in the ACCT process have been achieved.
8. The absence of an embedded system of single case management will put lives at risk as compliance with the ACCT process cannot be assured.
” Open source report
19 Jun 2019 Aram Ali Mustafa · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 2 Failure to provide sufficient details about safeguarding concerns and health care matters View source Failure to log safeguarding matters with the safeguarding hub regardless of a person's location in the system 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
Aram Ali Mustafa · 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
Aram Ali Mustafa, an asylum seeker living in initial accommodation, was found hanging by a scarf in his room on 4 February 2019 and was declared deceased at 23.10. The report identified concerns that earlier suicide and safeguarding information was not sufficiently detailed or logged across the organisations involved.
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; that does not assign responsibility.
PFD Monitor interpretation Failure to provide sufficient details about safeguarding concerns and health care matters
Wider context from the report “1. When he had first illegally entered the UK Mr Mustafa was deported to Italy on 29/10/18. Just before he was deported he confirmed he would kill himself if he was deported. He was provided with 1:1 constant watch and was successfully deported. When he re-entered the UK on 30/01/19 he was seen by a member of the immigration compliance and enforcement team who completed paperwork for the national asylum accommodation unit who in turn completed a service commission form requesting initial accommodation. The service commission form recorded that he had urgent medical needs and was a safeguarding concern however no detail was provided. Neither G4S nor Urban housing services requested any further details. A system needs to be put in place to ensure organisations provide sufficient details for providers to understand the nature of safeguarding concerns and health care matters. If there are GDPR concerns these could easily be addressed by a consent form at the time the person is first seen.
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure to log safeguarding matters with the safeguarding hub regardless of a person's location in the system
Wider context from the report “2. The events on 29/10/18 when he made a threat to kill himself were not logged with the safeguarding hub as he was about to be deported. There needs to be a system to ensure all safeguarding matters are logged regardless of where the person is in the system
” Open source report
31 Jan 2019 Andrew Stephen Carr · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 4 Failure to prevent drugs and other items being passed through the prison plumbing system View source Failure to record information about prisoner substance misuse and drug-related intelligence View source Uncontrolled use of contraband mobile phones contributing to substance misuse problems View source Failure to review information about prisoners entering the prison View source See 1 more concern
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
Andrew Stephen Carr · 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
Andrew Stephen Carr, a prisoner, was found unresponsive in his cell on 29 March 2018 and was pronounced dead at 22:53 after attempts to revive him were unsuccessful. The medical cause of death was recorded as the effects of a synthetic cannabinoid. Concerns included failures to identify and record information about his prior substance use, the known use of the prison plumbing system to pass drugs, and the role of contraband mobile phones in 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; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent drugs and other items being passed through the prison plumbing system
Wider context from the report “2. It had been known for approximately 5 years that drugs and other items could be passed through the plumbing system of the prison . No action was taken before Andrew’s death and the inquest heard that no solution had been found to the problem . This raises an ongoing concern for the wellbeing of prisoners and the risk of future deaths.
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure to record information about prisoner substance misuse and drug-related intelligence
Wider context from the report “1. The inquest heard evidence that before his transfer to Birmingham prison on 19/02/18 Andrew had been involved in 4 incidents of taking psychoactive substances resulting in a code blue being called. In addition there was intelligence that he may be giving out drugs. This information was available and passed onto Birmingham Prison - however they were not aware of it and did not record the information . The inquest heard that there was no time to review information of prisoners coming into the prison. This is a major concern as key information may not be identified and this poses a risk to the individual and other 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 G4S; that does not assign responsibility.
PFD Monitor interpretation Uncontrolled use of contraband mobile phones contributing to substance misuse problems
Wider context from the report “3. Many problems within the prison related to substances misuse are contributed to by the use of contraband mobile phones . The inquest heard evidence that blocking the use of mobile phones in prison would be very useful in mitigating this risk .
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure to review information about prisoners entering the prison
Wider context from the report “1. The inquest heard evidence that before his transfer to Birmingham prison on 19/02/18 Andrew had been involved in 4 incidents of taking psychoactive substances resulting in a code blue being called. In addition there was intelligence that he may be giving out drugs. This information was available and passed onto Birmingham Prison - however they were not aware of it and did not record the information. The inquest heard that there was no time to review information of prisoners coming into the prison . This is a major concern as key information may not be identified and this poses a risk to the individual and other prisoners.
” Open source report
11 Jan 2019 Ricardo Wayne Holgate · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 4 Lack of CCTV coverage on all prison wings View source Failure to adequately manage illicit substance misuse in the prison View source Unavailability of airport-style scanners at prisoner reception and the visitor area View source Failure to prevent the use and supply of illicit substances in the prison View source See 1 more concern
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
Ricardo Wayne Holgate · 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
Ricardo Wayne Holgate was found dead in his cell at Birmingham Prison on the morning of 26 March 2018. The post-mortem recorded coronary artery thrombosis and atherosclerosis, with the combined effects of synthetic cannabinoid and codeine. The inquest identified significant concerns about the supply and use of illicit substances, staffing levels, staff training and experience, and inconsistent management and reporting of prisoners affected by such substances.
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; that does not assign responsibility.
PFD Monitor interpretation Lack of CCTV coverage on all prison wings
Wider context from the report “1. The new Governing Governor confirmed that further steps are necessary to improve the management of illicit substance misuse. He confirmed the prison requires CCTV on all wings and airport style scanners – one in reception for prisoners and one in the visitor area.
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure to adequately manage illicit substance misuse in the prison
Wider context from the report “1. The new Governing Governor confirmed that further steps are necessary to improve the management of illicit substance misuse . He confirmed the prison requires CCTV on all wings and airport style scanners – one in reception for prisoners and one in the visitor area.
” 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; that does not assign responsibility.
PFD Monitor interpretation Unavailability of airport-style scanners at prisoner reception and the visitor area
Wider context from the report “1. The new Governing Governor confirmed that further steps are necessary to improve the management of illicit substance misuse. He confirmed the prison requires CCTV on all wings and airport style scanners – one in reception for prisoners and one in the visitor area .
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent the use and supply of illicit substances in the prison
Wider context from the report “2. Much progress has been made as a result of the appointment of the Governing Governor Paul Newton. His appointment was for 6 months. He advised at the inquest that there is much more work to do and extension of his appointment would allow further work to be undertaken to reduce the use and supply of illicit substances in the prison and to keep inmates safe.
” Open source report
18 Dec 2018 John Anthony Delahaye · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 5 Failure to conduct a welfare check on cell unlock View source Failure to ensure healthcare attendance at ACCT reviews View source Unreliable recording of relevant past and current medical conditions View source Lack of clarity in the in possession medication risk assessment question View source Failure to use the in possession medication risk assessment View source See 2 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
John Anthony Delahaye · 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
John Anthony Delahaye was found dead in his cell at HMP Birmingham on 5 March 2018 after taking an insulin overdose. The report identified concerns about the clarity and use of medication risk assessments, incomplete medical records, the absence of healthcare involvement in ACCT reviews, and the failure to carry out a welfare check when his cell was unlocked.
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; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct a welfare check on cell unlock
Wider context from the report “4. On the morning of the 5th March 2018 Mr. Delahaye’s cell had been unlocked at approximately 07:50. It is likely that he was already dead at this time (and had been so for some hours) but he was not found because the prison custody officer who unlocked his cell did not look into the cell or seek any kind of acknowledgement from Mr. Delahaye. It was acknowledged by the relevant PCO and by the Safer Custody Manager that unlock ought to have involved a welfare check. The Safer Custody Manager’s evidence is that the need for a welfare check on unlock has been emphasised to senior managers and leads through a bilateral document covered at formal briefings. However, it was not clear how this is then communicated down to the individual custody officers and how they are being audited to make sure they are conducting a welfare check on unlock. The absence of a welfare check creates a risk that a prisoner in need of life saving assistance at the time of unlock is not identified.
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure healthcare attendance at ACCT reviews
Wider context from the report “3. No member of the healthcare team was present at any of Mr. Delahaye’s ACCT reviews. It was identified during the inquest that a member of either the mental health team, primary care or the drug/alcohol service ought to have been present at the first review at least. It was the evidence of a first line manager who had involvement in the ACCT that a member of the custodial team had contacted healthcare and asked them to attend but this was not documented and the healthcare team maintained they were unaware of the date of the first review. Whilst the ACCT book provides a checklist of actions to be undertaken at various times it does not include making healthcare aware of the first review. As this is a national Ministry of Justice form, HMP Birmingham can’t change it but a failure to inform healthcare of an ACCT review could result in useful knowledge or expertise not being available to the ACCT team and could put lives at risk.
” 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; that does not assign responsibility.
PFD Monitor interpretation Unreliable recording of relevant past and current medical conditions
Wider context from the report “2. During the inquest it emerged that the mental health nurse who assessed Mr. Delahaye on the 2nd January 2018 and the GP who assessed him for in possession medication on the 29th January 2018, had not identified from his notes all relevant past medical conditions. It emerged that whilst the System One records (a case management system used across the prison estate) has the facility to provide a summary of significant past and current medical conditions, it is not reliable at HMP Birmingham because conditions are not consistently given the correct ‘read code’ . Evidence from the NHS England clinical reviewer, ████████, was that this problem is not unique to HMP Birmingham and is found in other prison healthcare teams and requires a change of culture and practice to bring the system for read coding into line with that in the community. The absence of a reliable source for quickly identifying relevant past and current medical conditions puts lives at risk from misinformed decision making.
” 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; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity in the in possession medication risk assessment question
Wider context from the report “1. There is confusion surrounding the meaning of the following question from NHS England’s national clinical template for in possession Risk Assessments in the Secure Estate : “Have you had problems in the last 6 months with not taking, or not remembering to take your medicines as prescribed?” The Risk Assessment had not been used in the assessment for Mr. Delahaye’s in possession modification on the 29th January 2018 when it ought to have been. However, during the course of considering what the outcome would have been if the risk assessment had been undertaken, more than one clinician interpreted the question as pertaining only to consideration of incidents where medication had not been taken. It was the Coroner’s view that the question is also asking about incidents where medication may have been taken but not “as prescribed” thus encompassing an overdose (accidental or deliberate). The question is not clear and this creates a risk that the score generated may be incorrect and in possession medication may be authorised where it ought not to be, putting lives at risk.
2. During the inquest it emerged that the mental health nurse who assessed Mr. Delahaye on the 2nd January 2018 and the GP who assessed him for in possession medication on the 29th January 2018, had not identified from his notes all relevant past medical conditions. It emerged that whilst the System One records (a case management system used across the prison estate) has the facility to provide a summary of significant past and current medical conditions, it is not reliable at HMP Birmingham because conditions are not consistently given the correct ‘read code’. Evidence from the NHS England clinical reviewer, ████████, was that this problem is not unique to HMP Birmingham and is found in other prison healthcare teams and requires a change of culture and practice to bring the system for read coding into line with that in the community. The absence of a reliable source for quickly identifying relevant past and current medical conditions puts lives at risk from misinformed decision making.
3. No member of the healthcare team was present at any of Mr. Delahaye’s ACCT reviews. It was identified during the inquest that a member of either the mental health team, primary care or the drug/alcohol service ought to have been present at the first review at least. It was the evidence of a first line manager who had involvement in the ACCT that a member of the custodial team had contacted healthcare and asked them to attend but this was not documented and the healthcare team maintained they were unaware of the date of the first review. Whilst the ACCT book provides a checklist of actions to be undertaken at various times it does not include making healthcare aware of the first review. As this is a national Ministry of Justice form, HMP Birmingham can’t change it but a failure to inform healthcare of an ACCT review could result in useful knowledge or expertise not being available to the ACCT team and could put lives at risk.
4. On the morning of the 5th March 2018 Mr. Delahaye’s cell had been unlocked at approximately 07:50. It is likely that he was already dead at this time (and had been so for some hours) but he was not found because the prison custody officer who unlocked his cell did not look into the cell or seek any kind of acknowledgement from Mr. Delahaye. It was acknowledged by the relevant PCO and by the Safer Custody Manager that unlock ought to have involved a welfare check. The Safer Custody Manager’s evidence is that the need for a welfare check on unlock has been emphasised to senior managers and leads through a bilateral document covered at formal briefings. However, it was not clear how this is then communicated down to the individual custody officers and how they are being audited to make sure they are conducting a welfare check on unlock. The absence of a welfare check creates a risk that a prisoner in need of life saving assistance at the time of unlock is not identified.
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure to use the in possession medication risk assessment
Wider context from the report “1. There is confusion surrounding the meaning of the following question from NHS England’s national clinical template for in possession Risk Assessments in the Secure Estate: “Have you had problems in the last 6 months with not taking, or not remembering to take your medicines as prescribed?” The Risk Assessment had not been used in the assessment for Mr. Delahaye’s in possession modification on the 29th January 2018 when it ought to have been. However, during the course of considering what the outcome would have been if the risk assessment had been undertaken, more than one clinician interpreted the question as pertaining only to consideration of incidents where medication had not been taken. It was the Coroner’s view that the question is also asking about incidents where medication may have been taken but not “as prescribed” thus encompassing an overdose (accidental or deliberate). The question is not clear and this creates a risk that the score generated may be incorrect and in possession medication may be authorised where it ought not to be, putting lives at risk.
2. During the inquest it emerged that the mental health nurse who assessed Mr. Delahaye on the 2nd January 2018 and the GP who assessed him for in possession medication on the 29th January 2018, had not identified from his notes all relevant past medical conditions. It emerged that whilst the System One records (a case management system used across the prison estate) has the facility to provide a summary of significant past and current medical conditions, it is not reliable at HMP Birmingham because conditions are not consistently given the correct ‘read code’. Evidence from the NHS England clinical reviewer, ████████, was that this problem is not unique to HMP Birmingham and is found in other prison healthcare teams and requires a change of culture and practice to bring the system for read coding into line with that in the community. The absence of a reliable source for quickly identifying relevant past and current medical conditions puts lives at risk from misinformed decision making.
3. No member of the healthcare team was present at any of Mr. Delahaye’s ACCT reviews. It was identified during the inquest that a member of either the mental health team, primary care or the drug/alcohol service ought to have been present at the first review at least. It was the evidence of a first line manager who had involvement in the ACCT that a member of the custodial team had contacted healthcare and asked them to attend but this was not documented and the healthcare team maintained they were unaware of the date of the first review. Whilst the ACCT book provides a checklist of actions to be undertaken at various times it does not include making healthcare aware of the first review. As this is a national Ministry of Justice form, HMP Birmingham can’t change it but a failure to inform healthcare of an ACCT review could result in useful knowledge or expertise not being available to the ACCT team and could put lives at risk.
4. On the morning of the 5th March 2018 Mr. Delahaye’s cell had been unlocked at approximately 07:50. It is likely that he was already dead at this time (and had been so for some hours) but he was not found because the prison custody officer who unlocked his cell did not look into the cell or seek any kind of acknowledgement from Mr. Delahaye. It was acknowledged by the relevant PCO and by the Safer Custody Manager that unlock ought to have involved a welfare check. The Safer Custody Manager’s evidence is that the need for a welfare check on unlock has been emphasised to senior managers and leads through a bilateral document covered at formal briefings. However, it was not clear how this is then communicated down to the individual custody officers and how they are being audited to make sure they are conducting a welfare check on unlock. The absence of a welfare check creates a risk that a prisoner in need of life saving assistance at the time of unlock is not identified.
” Open source report
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.
×
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; 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; 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 2 Lack of sufficient ACCT training among staff View source Failure to adhere to mandatory ACCT process provisions 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
John Brandon Betteridge · 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
John Brandon Betteridge was remanded to HMP Durham on 22 May 2015 and was found dead in his cell on 26 May 2015 after hanging himself. Concerns included gaps in staff training and failures to follow mandatory ACCT procedures, including the closure of the ACCT without healthcare staff present. The inquest found that the absence of his prescription medication and the fact that he was not on an open ACCT probably contributed more than minimally to his death.
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; that does not assign responsibility.
PFD Monitor interpretation Lack of sufficient ACCT training among staff
Wider context from the report “(1) A member of the Healthcare staff indicated that at the time of the death, though she was working in the prison, she had not received any ACCT training. I was told that ACCT training is now part of Healthcare staff induction training. A prison GP with 11 years’ experience of working in prisons stated that he had never received ACCT training though he had opened ACCTs. A Senior Officer who chaired the first review of the ACCT at which the ACCT was closed) believed it was good practice but did not know it was mandatory that healthcare staff should be present at such a review. The inquest has shown that notwithstanding that the ACCT process has been in existence for a number of years, some staff were working without having received any training and some either not had sufficient training or had forgotten it or were not applying it with the result that mandatory provisions in the ACCT process were not being adhered to. The inquest has indicated a clear training need.
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure to adhere to mandatory ACCT process provisions
Wider context from the report “(1) A member of the Healthcare staff indicated that at the time of the death, though she was working in the prison, she had not received any ACCT training. I was told that ACCT training is now part of Healthcare staff induction training. A prison GP with 11 years’ experience of working in prisons stated that he had never received ACCT training though he had opened ACCTs. A Senior Officer who chaired the first review of the ACCT at which the ACCT was closed) believed it was good practice but did not know it was mandatory that healthcare staff should be present at such a review. The inquest has shown that notwithstanding that the ACCT process has been in existence for a number of years, some staff were working without having received any training and some either not had sufficient training or had forgotten it or were not applying it with the result that mandatory provisions in the ACCT process were not being adhered to . The inquest has indicated a clear training need.
” Open source report
Concerns raised 11 Serious drug problem in the prison View source Failure of healthcare and discipline staff to know the overdose policy and prescribed response View source Complacency about prisoners presenting under the influence of drugs View source Failure to request emergency attendance by the on-duty nurse View source Failure of healthcare and discipline staff to provide an integrated response to drug-related presentations View source Failure to prepare an ongoing treatment plan for prisoners receiving nursing care View source Lack of formal training and detailed understanding of the current overdose policy View source Inadequate recording of nursing care and required actions View source Lack of operational guidance for responding to suspected overdoses View source Complacency and acceptance by staff of the prison drug problem View source Delays and uncertainty in calling an emergency ambulance and using the code blue call View source See 8 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
Kevin Anthony Forster · 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
Kevin Anthony Forster died in his prison cell at HMP Durham on 14 September 2014 after taking drugs he had hidden within his body. Staff identified that he was under the influence of an unknown substance, but no thorough or clinical assessment was undertaken. The principal concerns included inadequate policies, training, assessment, observation, treatment planning, communication and emergency response to prisoners who may have overdosed.
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; that does not assign responsibility.
PFD Monitor interpretation Serious drug problem in the prison
Wider context from the report “1. It was clear from evidence that there is a serious drug problem in HMP Durham . This has led to a degree of complacency and acceptance by staff of that situation.
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure of healthcare and discipline staff to know the overdose policy and prescribed response
Wider context from the report “2. Healthcare staff were unaware of what, if any, drugs policy was in place at the time . A policy known as a “Drugs Overdose Policy” which had, in various guises been in operation since 2008 included a definition of overdose as the “purposeful or accidental act of ingesting an amount of a drug or substance that may cause harm to health”. As such, the ingestion of unknown drugs is de facto harmful to health and would constitute an overdose which should lead to the triggering of the Overdose Policy. Both discipline and healthcare staff were unaware of the policy, the “overdose” definition and the prescribed steps which should then ensue .
” 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; that does not assign responsibility.
PFD Monitor interpretation Complacency about prisoners presenting under the influence of drugs
Wider context from the report “9. As mentioned earlier the evidence indicated that there was a degree of complacency about prisoners presenting under the influence of drugs and the risks associated therewith (at handover one officer said to another “there are some prisoners sleeping it off”). Due to the scale of the issue, the potential risk to health of prisoners is such that there needs to be absolute clarity of response and care for prisoners who so present. The evidence indicated that a more integrated approach between healthcare staff and discipline staff would be beneficial notwithstanding there were good lines of communication between the two.
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure to request emergency attendance by the on-duty nurse
Wider context from the report “7. Discipline staff summoned healthcare staff and perhaps not appreciating the significance of the apparent health of the deceased, did not call for the on-duty nurse to attend as an emergency, but just asked for the nurse to attend . Such an oversight could lead to a delay which in certain circumstances might be very significant.
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure of healthcare and discipline staff to provide an integrated response to drug-related presentations
Wider context from the report “9. As mentioned earlier the evidence indicated that there was a degree of complacency about prisoners presenting under the influence of drugs and the risks associated therewith (at handover one officer said to another “there are some prisoners sleeping it off”). Due to the scale of the issue, the potential risk to health of prisoners is such that there needs to be absolute clarity of response and care for prisoners who so present. The evidence indicated that a more integrated approach between healthcare staff and discipline staff would be beneficial notwithstanding there were good lines of communication between the two.
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure to prepare an ongoing treatment plan for prisoners receiving nursing care
Wider context from the report “6. There was a lack of an on-going treatment plan prepared for the deceased by nursing staff who attended on him and there was inadequate recording that they had done and what they had to do.
” 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; that does not assign responsibility.
PFD Monitor interpretation Lack of formal training and detailed understanding of the current overdose policy
Wider context from the report “3. Upon obtaining the contract for healthcare at HMP Durham, G4S have instituted have implemented a new policy, but evidence was given that staff had not been given any formal training on it , though the document (running to 12 pages) had been emailed. Evidence indicated that there was still a lack of appreciation of the detail of the policy now in force .
” 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; that does not assign responsibility.
PFD Monitor interpretation Inadequate recording of nursing care and required actions
Wider context from the report “6. There was a lack of an on-going treatment plan prepared for the deceased by nursing staff who attended on him and there was inadequate recording that they had done and what they had to do .
” 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; that does not assign responsibility.
PFD Monitor interpretation Lack of operational guidance for responding to suspected overdoses
Wider context from the report “4. The evidence indicated that there was a lack of guidance as to how staff should react when faced with a person who had overdosed ; no local procedures as envisaged by the policy were disclosed , what should be done where there is no indicator as to what substance had been ingested and what would be the appropriate level of observations recognising that (Policy paragraph 8.1) symptoms may develop later .
” 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; that does not assign responsibility.
PFD Monitor interpretation Complacency and acceptance by staff of the prison drug problem
Wider context from the report “1. It was clear from evidence that there is a serious drug problem in HMP Durham. This has led to a degree of complacency and acceptance by staff of that situation .
” 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; that does not assign responsibility.
PFD Monitor interpretation Delays and uncertainty in calling an emergency ambulance and using the code blue call
Wider context from the report “8. The evidence indicated that there was a delay (albeit a short one) in either healthcare or discipline staff calling for an emergency ambulance to attend and/or whether code blue as an expression was used . Other inquests have clearly identified issues at the establishment about the calling of an emergency ambulance.
” Open source report
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.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
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; 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; 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; 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
Concerns raised 6 Failure to make detailed notes in detainees’ custody medical records View source Lack of verbal consultation between medical practitioners and custody sergeants about detainee concerns and observation levels View source Insufficient targeted training on drug and alcohol-related risks in custody View source Insufficient training emphasis on correct observation levels View source Lack of joint training exercises for medical practitioners, custody sergeants, custody detention officers and assistants View source Failure to specify detainee observation levels precisely 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
Name not published · 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
The deceased was arrested on 2 October 2011 and held in custody, where he received prescribed methadone and medication for alcohol withdrawal. He was found unresponsive in his cell shortly before 9.00pm on 3 October 2011; the recorded medical cause of death was methadone intoxication, with alcohol withdrawal in a chronic alcoholic also identified. Concerns included communication between medical practitioners and custody staff, inconsistent observation levels, joint training, and training on drug and alcohol-related risks.
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; that does not assign responsibility.
PFD Monitor interpretation Failure to make detailed notes in detainees’ custody medical records
Wider context from the report “1. That consideration be given to issuing guidance that whenever a detainee is attended upon by a medical practitioner there should be a verbal consultation between the medical practitioner and custody sergeant as to any issues of concern and the level of observations to be had for that detainee in addition to the medical practitioner making detailed notes on the detainee’s custody medical 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 G4S; that does not assign responsibility.
PFD Monitor interpretation Lack of verbal consultation between medical practitioners and custody sergeants about detainee concerns and observation levels
Wider context from the report “1. That consideration be given to issuing guidance that whenever a detainee is attended upon by a medical practitioner there should be a verbal consultation between the medical practitioner and custody sergeant as to any issues of concern and the level of observations to be had for that detainee in addition to the medical practitioner making detailed notes on the detainee’s custody medical 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 G4S; that does not assign responsibility.
PFD Monitor interpretation Insufficient targeted training on drug and alcohol-related risks in custody
Wider context from the report “5. That training should include targeted training on the risks and dangers of drug and alcohol abuse, including methadone intoxication and alcohol withdrawal , particularly if the detainee is likely to be in custody for upwards of 24 hours.
” 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; that does not assign responsibility.
PFD Monitor interpretation Insufficient training emphasis on correct observation levels
Wider context from the report “3. That training should provide targeted emphasis on the correct levels of observation .
” 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; that does not assign responsibility.
PFD Monitor interpretation Lack of joint training exercises for medical practitioners, custody sergeants, custody detention officers and assistants
Wider context from the report “2. That consideration be given to the provision of joint training exercises for medical practitioners, custody sergeants and custody detention officers and assistants .
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure to specify detainee observation levels precisely
Wider context from the report “4. That consideration should be given to eliminating the phrase ‘continue observations at the current level’ and require that doctors and custody sergeants specify the level of observation precisely .
” 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