Gartree Prison

Justice · Prison or young offender institution

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First report 5 May 2016•Latest report 5 May 2016

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports
1

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Concerns and recipient responses

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

  1. Leicester City and South Leicestershire

    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

Data last updated 7 September 2026