Concerns raised 6 Failure to provide robust, effective and event-responsive complex case planning View source Failure to assess overdose-related intentions and inappropriate drug access for safeguarding purposes View source Lack of ready access to relevant risk-assessment and case-management information across healthcare and prison records View source Failure to formalise multidisciplinary team meetings View source Failure to investigate suspected overdose events and apply learning outcomes View source Under-utilisation of enhanced case management for complex prisoners View source See 3 more concerns
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AI-generated summary
Ahmedreza Fathi · 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
Ahmedreza Fathi was a serving prisoner at HMP Gartree who died by suicide in May 2015 through a combination of plastic bag asphyxia and multi-drug toxicity. The report identified concerns about inadequate case planning, fragmented communication and information-sharing, inappropriate observation levels, and insufficient response to an earlier overdose.
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 Gartree Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to provide robust, effective and event-responsive complex case planning
Wider context from the report “1. Healthcare complex case planning was not robust or effective , and was not reviewed or updated in response to subsequent events . Multi-disciplinary team meetings, if they took place, were not formalised and there was no ready access to all relevant information relating to risk assessment and case management through either System1 (the medical record storage and case management system) held by healthcare, or the ACCT document held by the 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 Gartree Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to assess overdose-related intentions and inappropriate drug access for safeguarding purposes
Wider context from the report “3. Mr Fathi was taken to hospital with (on the balance of probabilities) an earlier overdose, some weeks before he lost his life. Neither the prison services nor healthcare considered the significance of this event, raised any hospital enquiries or completed an accident/near-miss incident report procedure and applied learning outcomes. This was a missed opportunity to consider Mr Fathi's intentions, his ability to access drugs inappropriately and to take appropriate safeguarding actions . Consideration should be given to adopting a system that ensures investigating such events on each occasion to ensure lessons can be learnt.
” 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 Gartree Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of ready access to relevant risk-assessment and case-management information across healthcare and prison records
Wider context from the report “1. Healthcare complex case planning was not robust or effective, and was not reviewed or updated in response to subsequent events. Multi-disciplinary team meetings, if they took place, were not formalised and there was no ready access to all relevant information relating to risk assessment and case management through either System1 (the medical record storage and case management system) held by healthcare, or the ACCT document held by the 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 Gartree Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to formalise multidisciplinary team meetings
Wider context from the report “1. Healthcare complex case planning was not robust or effective, and was not reviewed or updated in response to subsequent events. Multi-disciplinary team meetings, if they took place, were not formalised and there was no ready access to all relevant information relating to risk assessment and case management through either System1 (the medical record storage and case management system) held by healthcare, or the ACCT document held by the 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 Gartree Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to investigate suspected overdose events and apply learning outcomes
Wider context from the report “3. Mr Fathi was taken to hospital with (on the balance of probabilities) an earlier overdose, some weeks before he lost his life. Neither the prison services nor healthcare considered the significance of this event, raised any hospital enquiries or completed an accident/near-miss incident report procedure and applied learning outcomes . This was a missed opportunity to consider Mr Fathi's intentions, his ability to access drugs inappropriately and to take appropriate safeguarding actions. Consideration should be given to adopting a system that ensures investigating such events on each occasion to ensure lessons can be learnt.
” 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 Gartree Prison; that does not assign responsibility.
PFD Monitor interpretation Under-utilisation of enhanced case management for complex prisoners
Wider context from the report “2. The enhanced case management system referred to in PSI 64/11 was under-utilised for a prisoner of this complexity and further consideration should be given to its role in situations of this nature.
” 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