21 Jun 2017 Michael Folley · Prevention of Future Deaths report Central Hampshire
View report summary
Concerns raised 13 Failure to complete SASH forms for risk information emerging outside current court detention View source Failure to ensure clarity about information available during prison reception View source Failure to ensure Detention Officer PER training is completed View source Failure to complete SASH forms for relevant recent self-harm or suicide risk View source Failure to ensure receipt and training for important medical and risk information at prison reception View source Cell safety features permitting door wedging and ligature use View source Radio connection delays affecting emergency information relay View source Failure to ensure secure handover of PER documentation View source Failure to provide PER staff with relevant previous self-harm and suicide risk information View source Failure of court custody staff to contribute relevant risk information to the PER View source Incomplete provision of anti-ligature protection on cell doors View source Failure to record checks of PER completion and quality View source Failure of regular maintenance checks to identify defective anti-barricade doors View source See 10 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
Michael Folley · 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
Michael Folley was remanded to HMP Winchester on 15 September 2017 and was found the following day suspended from a ligature made from torn bed sheets after barricading his cell door with mirrors and furniture. He was taken to hospital and died on 18 September 2017 after intensive care treatment. The principal concerns included the transfer and use of information about self-harm risk between police, court and prison; staff training; cell safety and maintenance; systems for checking barricaded cell doors; and the effectiveness of prison radios in relaying emergency calls.
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 GeoAmey PECS Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to complete SASH forms for risk information emerging outside current court detention
Wider context from the report “I was also left with a concern that GEOAmey staff would only complete a SASH form if the current risk was identified during Mr Folley’s detention at Portsmouth magistrates’ court and not if anything came to the attention of the court detention officer to indicate there was a risk of self-harm or suicide within the last month before arrest .
” 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 GeoAmey PECS Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure clarity about information available during prison reception
Wider context from the report “During the inquest, it became apparent that despite extensive questioning of police/custody staff, GEOAmey staff, prison officers and healthcare professionals, it would not be possible to establish with any degree of certainty exactly what information was available during the induction process once Mr Folley arrived at prison.
I heard from prison officers and a senior nurse involved in the reception process but there was no clarity regarding exactly what information was available to them namely, the PER itself, the HDLS reports or information that had clearly been faxed to the prison by court staff such as the warrants setting out the grounds for the remand.
” 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 GeoAmey PECS Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure Detention Officer PER training is completed
Wider context from the report “c) Detention Officer PER training may not have been completed if a DO had many years of experience in the police force which would give what he referred to as “grandfather rights” .
” 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 GeoAmey PECS Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to complete SASH forms for relevant recent self-harm or suicide risk
Wider context from the report “h) The suicide/self harm warning alert (SASH) at page 9 of the PER was meant to be completed if there was a risk of self-harm or suicide since arrest or within the last month . In other words, it was felt the relevant period to be considered was not just the current period of detention but also anything relevant within a month before arrest. In this case the SASH form was never completed .
” 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 GeoAmey PECS Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure receipt and training for important medical and risk information at prison reception
Wider context from the report “The nurse confirmed that at the time of Mr Folley’s reception checks he did not see the PER or HLDS reports but told me that he now does. In addition, he could not recall any specific training and the system for receipt of important medical information sounded haphazard as hardcopy documents were simply left on a desk .
” 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 GeoAmey PECS Limited; that does not assign responsibility.
PFD Monitor interpretation Cell safety features permitting door wedging and ligature use
Wider context from the report “I heard evidence that prisoners are issued with plastic mirrors that are frequently used as wedges in cell doors . This means officers are vigilant to ensure prisoners only have one mirror each and if there are more in a cell than necessary they will be removed. It was suggested that a thicker mirror could be issued or a mirror/reflective panel could be inserted into the wall. This was an ongoing process of replacement in the prison.
Window design was also being considered and I was informed a trial had begun prison to roll out a new type of window but that this could take up to 2 years to complete .
” 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 GeoAmey PECS Limited; that does not assign responsibility.
PFD Monitor interpretation Radio connection delays affecting emergency information relay
Wider context from the report “There was conflicting evidence during inquest about the effectiveness of when the Code Blue call was made and whether this resulted in any delay in the information being passed to the ambulance service. On balance of probabilities, the problem seemed to come from the fact that the custody manager did give the correct callsign but because there is a two second delay when pressing the radio button this may not have been picked up immediately in the control room . This is of significant concern both in respect of the safety prison officers but also the need to obtain medical help for prisoners and suggests the need to update the radio system
” 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 GeoAmey PECS Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure secure handover of PER documentation
Wider context from the report “e) The responsibility for the completion and quality of the PER rests with the releasing Custody Sergeant. When checking the detention log in the custody record in this case, there was no specific entry. This may not necessarily mean it was not checked by the custody sergeant but if it was then that action should be recorded.
f) It is the custody sergeant’s responsibility to ensure the safe transportation of a PER and associated documents by placing them in an envelope or other secure means that all documentation is safely handed over to the court custody officers .
” 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 GeoAmey PECS Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to provide PER staff with relevant previous self-harm and suicide risk information
Wider context from the report “b) Mr Folley was assessed as NCTS (no current thoughts of self-harm or suicide) and thus placed on the lowest observation rate of 60 minutes. However, access to previous data held on police (both internal and external) and other agency systems was not available to officers completing the PER and thus they could rely on current observations only . Despite this, it was essential to consider the risk of self-harm or suicide demonstrated and recorded over the previous months (July – September) not simply since detention on this occasion.
” 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 GeoAmey PECS Limited; that does not assign responsibility.
PFD Monitor interpretation Failure of court custody staff to contribute relevant risk information to the PER
Wider context from the report “I am concerned that the impression created was that GEOAmey staff do not actively engage in and contribute to the contents of the PER to highlight any information relevant to risk assessment irrespective of what source it comes from.
In addition, there was apparently no log of ████████ call to the court cells. The electronic PER had been checked and nothing was logged. There is no reason to believe ████████ call was not made and it is of concern that there was no apparent system for logging such a call let alone action in the contents of her request .
” 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 GeoAmey PECS Limited; that does not assign responsibility.
PFD Monitor interpretation Incomplete provision of anti-ligature protection on cell doors
Wider context from the report “I also heard that steps had been taken to fit anti-ligature strips in some but not all cell doors .
All of these suggestions seemed eminently sensible yet the pace of these changes does need to 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 GeoAmey PECS Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to record checks of PER completion and quality
Wider context from the report “e) The responsibility for the completion and quality of the PER rests with the releasing Custody Sergeant. When checking the detention log in the custody record in this case, there was no specific entry . This may not necessarily mean it was not checked by the custody sergeant but if it was then that action should be recorded .
f) It is the custody sergeant’s responsibility to ensure the safe transportation of a PER and associated documents by placing them in an envelope or other secure means that all documentation is safely handed over to the court custody officers.
” 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 GeoAmey PECS Limited; that does not assign responsibility.
PFD Monitor interpretation Failure of regular maintenance checks to identify defective anti-barricade doors
Wider context from the report “I heard evidence that every effort was made to gain quick access into Mr Folley self once it became apparent that he had barricaded the door. This was significantly hindered by painting the screws on the anti-barricade plate but significantly, by the fact that even when the plate was removed the bar would not open outwards towards this landing due to a brick hanging down in the door frame. Whilst it has to be accepted that Winchester prison is not a modern prison nevertheless this should have been picked up during regular maintenance checks . I was shown some records this tended to imply that either checks had not been carried out on a regular basis or the checks themselves were not adequate . Either way this is of concern.
” Open source report
Concerns raised 6 Failure to question unexplained SASH form transmission View source Lack of clarity about the designated recipient of SASH forms View source Failure of reception procedures under foreseeable high-demand conditions View source Failure of GEOAmey and prison reception staff to understand and keep each other informed about interconnecting procedures View source Failure of GEOAmey, prison and healthcare procedures to inter-operate safely View source Lack of a detailed, documented and tracked account of SASH form transmission View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Derek Thomas · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Derek Thomas died by suicide while in HMP Durham after arriving on remand and undergoing reception and first-night induction. Information suggesting suicidal intent was not adequately communicated or identified because of failures involving the SASH and PER forms across escort, prison reception and healthcare staff. The report raised concerns about procedures failing under demanding but foreseeable conditions, unclear inter-agency responsibilities, inadequate tracking of information, and poor interoperability between agencies.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to GeoAmey PECS Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to question unexplained SASH form transmission
Wider context from the report “(3) That Prison reception staff in their evidence were adamant that a SASH form could never have been overlooked. However, prison staff at every level could provide no detailed, documented and tracked, account for how the SASH form had reached the prison records for Mr Thomas. There is an over reliance on the fidelity of the system, even when it has failed. No questions were asked at any stage on 21st July 2014, when it it passed from GEOAmey staff, to reception staff, to healthcare, or thereafter as to how a SASH form had arrived in the prison without being previously noticed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to GeoAmey PECS Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about the designated recipient of SASH forms
Wider context from the report “(2) That the GEOAmey staff and Prison reception staff (including very experienced officers with both) had conflicting impressions of which Prison Officer (the one dealing with the warrants and Core record alternatively the one dealing with the property and the PER) was supposed to be the recipient of the SASH form. Training and refresher training as to their own procedures notwithstanding, there is a lack of appreciation by GEOAmey escort staff of the prison's reception procedures. There is a lack of awareness by prison staff of GEOAmey staff's ignorance of them. Alternatively, the prison reception staff develop the procedures without keeping GEOAmey staff informed. There is a tangible sense of one hand not knowing what the other is doing.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to GeoAmey PECS Limited; that does not assign responsibility.
PFD Monitor interpretation Failure of reception procedures under foreseeable high-demand conditions
Wider context from the report “(1) That the circumstances on the 21st July 2014 at the reception included an inexperienced officer being on duty in conditions which were particularly onerous. It was described as the busiest he had ever seen by another more senior officer who was called away to deal with an incident, just at the time Mr Thomas was arriving in reception. Prison staff were adamant that another officer would have filled the gap left (although the identity of the substituting prison officer was not provided). These circumstances were clearly very demanding but they were not unforeseeable and may be repeated in future. When the procedures were “stress-tested” in the way they were on 21st July 2014, they failed so that a SASH form went unnoticed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to GeoAmey PECS Limited; that does not assign responsibility.
PFD Monitor interpretation Failure of GEOAmey and prison reception staff to understand and keep each other informed about interconnecting procedures
Wider context from the report “(2) That the GEOAmey staff and Prison reception staff (including very experienced officers with both) had conflicting impressions of which Prison Officer (the one dealing with the warrants and Core record alternatively the one dealing with the property and the PER) was supposed to be the recipient of the SASH form. Training and refresher training as to their own procedures notwithstanding, there is a lack of appreciation by GEOAmey escort staff of the prison's reception procedures. There is a lack of awareness by prison staff of GEOAmey staff's ignorance of them. Alternatively, the prison reception staff develop the procedures without keeping GEOAmey staff informed. There is a tangible sense of one hand not knowing what the other is doing.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to GeoAmey PECS Limited; that does not assign responsibility.
PFD Monitor interpretation Failure of GEOAmey, prison and healthcare procedures to inter-operate safely
Wider context from the report “(5) That the above concerns go to the issue of the inter-operability of GEOAmey and prison and healthcare procedures, which is not yet addressed by any of the agencies. I note that the pilot scheme is designed to improve “information sharing” between agencies. I am concerned that this case provides a paradigm example of not just a failure in communication between agencies but a deeper failure in properly appreciating each other's procedures and potential weaknesses where they are supposed to inter-connect. Looked at holistically, the system is demonstrated to be dysfunctional in this case.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to GeoAmey PECS Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of a detailed, documented and tracked account of SASH form transmission
Wider context from the report “(3) That Prison reception staff in their evidence were adamant that a SASH form could never have been overlooked. However, prison staff at every level could provide no detailed, documented and tracked, account for how the SASH form had reached the prison records for Mr Thomas. There is an over reliance on the fidelity of the system, even when it has failed. No questions were asked at any stage on 21st July 2014, when it it passed from GEOAmey staff, to reception staff, to healthcare, or thereafter as to how a SASH form had arrived in the prison without being previously noticed.
” Open source report
×
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 Engage with other agencies to develop and share best-practice procedures and documentation.
Verbatim wording from the response “We appreciate other agencies’ procedures and have devised and revised our SOPs to comply with the HM Prison Service’s requirements set out in the PSOs and PSIs. We engage in dialogue with other agencies (where possible) to develop best practice, procedures and documentation to be shared between the agencies.” Source location 2015-0502-Response-by-GEOAMEY
Open published response
×
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 Requesting individual operating specifications from every establishment is not feasible because of the number of sites and resulting paperwork.
Verbatim wording from the response “There are 207 prisons from/to which we collect/escort 1,000s of prisoners per week. We also collect/escort prisoners from/to 100s of Courts, Police Stations and Detention Centres across the UK. It is not feasible for us to request from each establishment, nor for it to draw up, a specification sheet for individual operating processes. It would create an significant volume of paperwork for our officers.” Source location 2015-0502-Response-by-GEOAMEY
Open published response
×
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 Existing procedures and systems are considered correct and sufficient for safe custody and escort, with focused training addressing the concerns.
Verbatim wording from the response “We have taken your concerns on-board. We refer you to Mr Airey’s statement. There has been no change to our procedures regarding the SASH Form or the PER. Following this Inquest there has been no request by the MOJ or PECS for our procedures to be revised. We remain of the view that we have the correct procedures and systems in place for the safe custody and escort of prisoners and the Jury’s conclusion and your concerns regarding the company can be properly addressed by the additional focused training in place which has been completed by over 90% of our officers with the remaining officers to complete it as soon as possible.” Source location 2015-0502-Response-by-GEOAMEY
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The system is not dysfunctional; correct PER completion and document reading by prison and healthcare staff address interoperability concerns.
Verbatim wording from the response “It is unclear what further inter-operability could be put in place other than the correct completion of the PER by our officers (and/or others) and the reading of PER and SASH Forms by the prison and the Healthcare provider. Accordingly, we are of the view that the system is not “dysfunctional”.” Source location 2015-0502-Response-by-GEOAMEY
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Ministry of Justice has final responsibility for policy, procedures and documentation.
Verbatim wording from the response “The final say on policy, procedures and documentation is with the MOJ to whom we are contracted.” Source location 2015-0502-Response-by-GEOAMEY
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The contractor has no remit over HMP Durham staff compliance with Prison Service Instructions.
Verbatim wording from the response “The PER and any other available documentation including the SASH Form must be examined and prisoner interviewed in prison reception to assess the risk of self-harm or harm to others as part of the Cell Sharing Risk Assessment (paragraph 2.18). The information is recorded and shared with other departments and agencies (e.g. Healthcare) internally and externally and actions are to be documented (paragraphs 2.19 and 2.20). We have no remit over HMP Durham staff (who are MOJ employees) and their compliance with the PSIs.” Source location 2015-0502-Response-by-GEOAMEY
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The contractor has no contract, contact or input regarding prison healthcare provision, policies or procedures.
Verbatim wording from the response “We do not have any contract, dialogue or contact with the Healthcare provider at HMP Durham nor with any Healthcare provider at any prison across the UK. The contract for the provision of Healthcare facilities and the policies and procedures in place is between the MOJ and the Healthcare provider. We have no input into this.” Source location 2015-0502-Response-by-GEOAMEY
Open published response
Concerns raised 12 Limited Youth Offending Service staff training for the Social Services records system View source Insufficient capacity of supported accommodation View source Failure of frontline social services practitioners to identify when and where to make mental health referrals View source Lack of awareness among custody medical services of out-of-hours access to Children's Services records View source Failure to use previous psychiatric services information in assessment and Child in Need planning View source Inconsistent use of the Child in Need process for homeless young people View source Failure to routinely provide prisoner escort records to the Youth Offending Service View source Lack of a requirement for thorough mental health assessment of young people in custody View source Failure to obtain health-professional advice about risks following previous suicidal ideation View source Limited Youth Offending Service staff access to the Social Services records system View source Lack of a formal step-down process for young people leaving or disengaging from adult mental health services View source Failure to provide needs-based access to mental health and subsistence support for 16- and 17-year-olds in supported accommodation View source See 9 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
Peter Stanley · 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
Peter Stanley, aged 17, was found hanging in woodland on 2 August 2013 after a history of mental health concerns, suicidal thoughts and a previous suicide attempt. The report identified missed opportunities for mental health assessment and care, alongside concerns about information-sharing, homelessness and accommodation, custody assessments, and support for young people.
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 GeoAmey PECS Limited; that does not assign responsibility.
PFD Monitor interpretation Limited Youth Offending Service staff training for the Social Services records system
Wider context from the report “(10) It is understood that the number of Youth Offending Service staff who have access to, and training for, the Social Services records system is limited.
” 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 GeoAmey PECS Limited; that does not assign responsibility.
PFD Monitor interpretation Insufficient capacity of supported accommodation
Wider context from the report “(7) This case shows the need for a greater number of places in supported accommodation .
” 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 GeoAmey PECS Limited; that does not assign responsibility.
PFD Monitor interpretation Failure of frontline social services practitioners to identify when and where to make mental health referrals
Wider context from the report “(9) It is evident that front line social services practitioners are not always aware of when and where to make mental health referrals .
” 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 GeoAmey PECS Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness among custody medical services of out-of-hours access to Children's Services records
Wider context from the report “(3) On the basis of evidence given by ████████ Assistant Director of Fieldwork Services, Sheffield City Council, it is clear that the custody nurse could have accessed the Children's Services records for Peter on 14 July, even during the night, by calling the Social Services 'out of hours' team. Every local authority has an out of hours system (which would cover adults as well). However I am told that this is not generally known amongst those providing custody medical services .
” 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 GeoAmey PECS Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to use previous psychiatric services information in assessment and Child in Need planning
Wider context from the report “(11) There is no system to ensure that where there has been previous psychiatric services involvement by a young person that such information will be used to inform assessment and the 'Child in Need' planning process .
” 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 GeoAmey PECS Limited; that does not assign responsibility.
PFD Monitor interpretation Inconsistent use of the Child in Need process for homeless young people
Wider context from the report “(6) Peter was classed as 'intentionally homeless' after his release from court on 15 July. ████████ gave the court compelling evidence that this was wrong and that Peter should have been treated as a 'Child in Need'. Emphasis on the 'Child in Need' process when a young person is homeless would ensure proper assessment and sharing of information . Failures in sharing Peter's mental health history/needs were significant issues in this case . This emphasis is now standard practice in Sheffield but I understand it is not likely to be the case everywhere .
” 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 GeoAmey PECS Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely provide prisoner escort records to the Youth Offending Service
Wider context from the report “(5) A prisoner escort record (known commonly as a PER) would have been handed over from the police to the privatised court detention officers when Peter was produced before the magistrates. This contains details (inter alia) of risks, self harm issues, medical attention and warning markers. I understand that the Youth Offending Service believe that the PER should be routinely given to them it would inform assessments as to the immediate needs of the young person. This would only arise, of course, in the relatively few cases where the young person has spent a period in police cells.
” 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 GeoAmey PECS Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of a requirement for thorough mental health assessment of young people in custody
Wider context from the report “(4) There is no specific requirement that health professionals completing assessments of young persons in custody suites include a thorough assessment of mental health .
” 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 GeoAmey PECS Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain health-professional advice about risks following previous suicidal ideation
Wider context from the report “(12) There is no system to ensure that when a young person has presented with previous suicidal ideology that advice is taken from health professionals regarding the potential risks .
” 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 GeoAmey PECS Limited; that does not assign responsibility.
PFD Monitor interpretation Limited Youth Offending Service staff access to the Social Services records system
Wider context from the report “(10) It is understood that the number of Youth Offending Service staff who have access to, and training for, the Social Services records system is limited.
” 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 GeoAmey PECS Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of a formal step-down process for young people leaving or disengaging from adult mental health services
Wider context from the report “(2) When young people are discharged from, or have failed to engage with, Adult Mental Health Services there is no formal 'step-down' policy . The Sheffield Child Death Overview Panel advise me that this should include a referral to a Multi Agency Support Team or Community Youth team who can then establish a key worker and 'team around the child' approach.
” 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 GeoAmey PECS Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to provide needs-based access to mental health and subsistence support for 16- and 17-year-olds in supported accommodation
Wider context from the report “(13) There is no system to ensure that 16 and 17 year olds placed in supported accommodation have needs based access to support services, including mental health and subsistence , irrespective of whether they fall within s.20 of the Childrens Act.
” Open source report
6 Jan 2014 Billy Paul Thomas Salton · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 13 Failure to complete MEDACS assessment forms and care plans accurately View source Failure to document non-assessment and avoid misleading medical records View source Failure to obtain and review detained persons’ relevant medical information View source Lack of understanding of required custody observation levels and rationale View source Failure to accurately document custody cell checks View source Failure to complete prisoner transfer documentation accurately View source Failure to staff the Prisoner Processing Unit overnight View source Lack of staff knowledge of MEDACS policies and protocols View source Failure to transfer and replicate medical observation information during GEO AMEY custody View source Lack of specific instructions and effective positioning for CCTV cell monitoring View source Ineffective or absent handovers between custody staff View source Failure to accurately record custody visits and checks View source Failure to record custody risk assessments and rationale for unchanged assessments View source See 10 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
Billy Paul Thomas Salton · 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
Billy Paul Thomas Salton, who had epilepsy and was intermittently non-compliant with his medication, was detained at Cheadle Police Station without initially receiving his medication. He experienced seizures in custody and was later found collapsed in a cell at Stockport Magistrates’ Court; he died after being taken to hospital. The report identified concerns about medication verification and administration, recording and handovers, observation levels and cell checks, custody delays, and the accuracy and communication of medical and escort information.
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 GeoAmey PECS Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to complete MEDACS assessment forms and care plans accurately
Wider context from the report “1. During the course of the evidence I heard that Mr Salton had remained in custody overnight and was not progressed as quickly as he could have been whilst in custody as there was no-one available to interview him. This is as a result of GMP policy on how people are progressed through custody. The Prisoner Processing Unit is not staffed overnight which leads to people being in custody longer than they should be and bringing GMP “up against the requirements of the Police and Criminal Evidence Act”. GMP cannot indicate how many people may have been detained in custody longer than they should have been under their new policy.
2. There was a lack of understanding amongst the custody staff and staff from other agencies as to the level of observations Mr Salton was on and why he was on those observations. It is important that everyone who has care of someone in custody understands what the observations have been, what they should be, when they are to be carried out, whether rousing is required and why the observations are set as they are – i.e. what the medical condition/ concern is.
3. When the deceased is visited and checked all such visits should be accurately recorded on the custody record.
4. Risk assessments carried out whilst in police custody should be recorded when they are done. If there are no changes to a risk assessment then this should be recorded and any rationale noted.
5. Handovers between Custody Sergeants were ineffective and there was no handover between the Civilian Detention Staff. Important information was missed or lost in translation. Proper handovers should take place as to a detained person’s condition, risk assessment, any medical condition, level of visits and other important matters.
6. The Prisoner Escort Form was incorrectly completed. The final Custody Sergeant should ensure that the transferring documentation is accurate.
7. There were no specific instructions to monitor Mr Salton whilst he was in the CCTV cell. The CCTV screen is situated furthest away from the desk where someone in the back office is more likely to be seated (next to the security controls) meaning that there is less likelihood of them “glancing” at the CCTV screen.
1. MEDACS should ensure that all staff are fully aware of the content of any MEDACS policies or protocols, where these can be located in the police station and if necessary receive any required training on the same (the Court heard that ████████ was not aware of the MEDACS Epilepsy Policy).
2. MEDACS should receive a verbal report from Custody Staff and as much information as possible as to the detained person’s medical condition. Even if they are solely to administer medication MEDACS staff should read any previous medical notes from the same stay in custody.
3. All staff are reminded of the need to record information on the MEDACS Assessment Form including completing a Care Plan . Such a form should be completed accurately including any negative answers to questions asked .
4. If a doctor or nurse is unable to complete a medical assessment or is not assessing an individual then this should be explained and any potentially misleading information should not be recorded.
1. Staff should be reminded of the levels of observation (cell checks) required on detained persons whilst in their custody.
2. Staff should be reminded that all cell checks should be accurately documented.
3. GEO AMEY should ensure that their staff have knowledge of and fully read any documentation available when collecting a detained person. This is especially true of any medical information and if there is a medical reason why someone is on a certain level / type of observation that this is replicated whilst in the custody of GEO AMEY.
” 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 GeoAmey PECS Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to document non-assessment and avoid misleading medical records
Wider context from the report “1. During the course of the evidence I heard that Mr Salton had remained in custody overnight and was not progressed as quickly as he could have been whilst in custody as there was no-one available to interview him. This is as a result of GMP policy on how people are progressed through custody. The Prisoner Processing Unit is not staffed overnight which leads to people being in custody longer than they should be and bringing GMP “up against the requirements of the Police and Criminal Evidence Act”. GMP cannot indicate how many people may have been detained in custody longer than they should have been under their new policy.
2. There was a lack of understanding amongst the custody staff and staff from other agencies as to the level of observations Mr Salton was on and why he was on those observations. It is important that everyone who has care of someone in custody understands what the observations have been, what they should be, when they are to be carried out, whether rousing is required and why the observations are set as they are – i.e. what the medical condition/ concern is.
3. When the deceased is visited and checked all such visits should be accurately recorded on the custody record.
4. Risk assessments carried out whilst in police custody should be recorded when they are done. If there are no changes to a risk assessment then this should be recorded and any rationale noted.
5. Handovers between Custody Sergeants were ineffective and there was no handover between the Civilian Detention Staff. Important information was missed or lost in translation. Proper handovers should take place as to a detained person’s condition, risk assessment, any medical condition, level of visits and other important matters.
6. The Prisoner Escort Form was incorrectly completed. The final Custody Sergeant should ensure that the transferring documentation is accurate.
7. There were no specific instructions to monitor Mr Salton whilst he was in the CCTV cell. The CCTV screen is situated furthest away from the desk where someone in the back office is more likely to be seated (next to the security controls) meaning that there is less likelihood of them “glancing” at the CCTV screen.
1. MEDACS should ensure that all staff are fully aware of the content of any MEDACS policies or protocols, where these can be located in the police station and if necessary receive any required training on the same (the Court heard that ████████ was not aware of the MEDACS Epilepsy Policy).
2. MEDACS should receive a verbal report from Custody Staff and as much information as possible as to the detained person’s medical condition. Even if they are solely to administer medication MEDACS staff should read any previous medical notes from the same stay in custody.
3. All staff are reminded of the need to record information on the MEDACS Assessment Form including completing a Care Plan. Such a form should be completed accurately including any negative answers to questions asked.
4. If a doctor or nurse is unable to complete a medical assessment or is not assessing an individual then this should be explained and any potentially misleading information should not be recorded .
1. Staff should be reminded of the levels of observation (cell checks) required on detained persons whilst in their custody.
2. Staff should be reminded that all cell checks should be accurately documented.
3. GEO AMEY should ensure that their staff have knowledge of and fully read any documentation available when collecting a detained person. This is especially true of any medical information and if there is a medical reason why someone is on a certain level / type of observation that this is replicated whilst in the custody of GEO AMEY.
” 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 GeoAmey PECS Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain and review detained persons’ relevant medical information
Wider context from the report “1. During the course of the evidence I heard that Mr Salton had remained in custody overnight and was not progressed as quickly as he could have been whilst in custody as there was no-one available to interview him. This is as a result of GMP policy on how people are progressed through custody. The Prisoner Processing Unit is not staffed overnight which leads to people being in custody longer than they should be and bringing GMP “up against the requirements of the Police and Criminal Evidence Act”. GMP cannot indicate how many people may have been detained in custody longer than they should have been under their new policy.
2. There was a lack of understanding amongst the custody staff and staff from other agencies as to the level of observations Mr Salton was on and why he was on those observations. It is important that everyone who has care of someone in custody understands what the observations have been, what they should be, when they are to be carried out, whether rousing is required and why the observations are set as they are – i.e. what the medical condition/ concern is.
3. When the deceased is visited and checked all such visits should be accurately recorded on the custody record.
4. Risk assessments carried out whilst in police custody should be recorded when they are done. If there are no changes to a risk assessment then this should be recorded and any rationale noted.
5. Handovers between Custody Sergeants were ineffective and there was no handover between the Civilian Detention Staff. Important information was missed or lost in translation. Proper handovers should take place as to a detained person’s condition, risk assessment, any medical condition, level of visits and other important matters.
6. The Prisoner Escort Form was incorrectly completed. The final Custody Sergeant should ensure that the transferring documentation is accurate.
7. There were no specific instructions to monitor Mr Salton whilst he was in the CCTV cell. The CCTV screen is situated furthest away from the desk where someone in the back office is more likely to be seated (next to the security controls) meaning that there is less likelihood of them “glancing” at the CCTV screen.
1. MEDACS should ensure that all staff are fully aware of the content of any MEDACS policies or protocols, where these can be located in the police station and if necessary receive any required training on the same (the Court heard that ████████ was not aware of the MEDACS Epilepsy Policy).
2. MEDACS should receive a verbal report from Custody Staff and as much information as possible as to the detained person’s medical condition . Even if they are solely to administer medication MEDACS staff should read any previous medical notes from the same stay in custody .
3. All staff are reminded of the need to record information on the MEDACS Assessment Form including completing a Care Plan. Such a form should be completed accurately including any negative answers to questions asked.
4. If a doctor or nurse is unable to complete a medical assessment or is not assessing an individual then this should be explained and any potentially misleading information should not be recorded.
1. Staff should be reminded of the levels of observation (cell checks) required on detained persons whilst in their custody.
2. Staff should be reminded that all cell checks should be accurately documented.
3. GEO AMEY should ensure that their staff have knowledge of and fully read any documentation available when collecting a detained person. This is especially true of any medical information and if there is a medical reason why someone is on a certain level / type of observation that this is replicated whilst in the custody of GEO AMEY.
” 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 GeoAmey PECS Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of required custody observation levels and rationale
Wider context from the report “1. During the course of the evidence I heard that Mr Salton had remained in custody overnight and was not progressed as quickly as he could have been whilst in custody as there was no-one available to interview him. This is as a result of GMP policy on how people are progressed through custody. The Prisoner Processing Unit is not staffed overnight which leads to people being in custody longer than they should be and bringing GMP “up against the requirements of the Police and Criminal Evidence Act”. GMP cannot indicate how many people may have been detained in custody longer than they should have been under their new policy.
2. There was a lack of understanding amongst the custody staff and staff from other agencies as to the level of observations Mr Salton was on and why he was on those observations . It is important that everyone who has care of someone in custody understands what the observations have been, what they should be, when they are to be carried out, whether rousing is required and why the observations are set as they are – i.e. what the medical condition/ concern is.
3. When the deceased is visited and checked all such visits should be accurately recorded on the custody record.
4. Risk assessments carried out whilst in police custody should be recorded when they are done. If there are no changes to a risk assessment then this should be recorded and any rationale noted.
5. Handovers between Custody Sergeants were ineffective and there was no handover between the Civilian Detention Staff. Important information was missed or lost in translation. Proper handovers should take place as to a detained person’s condition, risk assessment, any medical condition, level of visits and other important matters.
6. The Prisoner Escort Form was incorrectly completed. The final Custody Sergeant should ensure that the transferring documentation is accurate.
7. There were no specific instructions to monitor Mr Salton whilst he was in the CCTV cell. The CCTV screen is situated furthest away from the desk where someone in the back office is more likely to be seated (next to the security controls) meaning that there is less likelihood of them “glancing” at the CCTV screen.
1. MEDACS should ensure that all staff are fully aware of the content of any MEDACS policies or protocols, where these can be located in the police station and if necessary receive any required training on the same (the Court heard that ████████ was not aware of the MEDACS Epilepsy Policy).
2. MEDACS should receive a verbal report from Custody Staff and as much information as possible as to the detained person’s medical condition. Even if they are solely to administer medication MEDACS staff should read any previous medical notes from the same stay in custody.
3. All staff are reminded of the need to record information on the MEDACS Assessment Form including completing a Care Plan. Such a form should be completed accurately including any negative answers to questions asked.
4. If a doctor or nurse is unable to complete a medical assessment or is not assessing an individual then this should be explained and any potentially misleading information should not be recorded.
1. Staff should be reminded of the levels of observation (cell checks) required on detained persons whilst in their custody.
2. Staff should be reminded that all cell checks should be accurately documented.
3. GEO AMEY should ensure that their staff have knowledge of and fully read any documentation available when collecting a detained person. This is especially true of any medical information and if there is a medical reason why someone is on a certain level / type of observation that this is replicated whilst in the custody of GEO AMEY.
” 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 GeoAmey PECS Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to accurately document custody cell checks
Wider context from the report “1. During the course of the evidence I heard that Mr Salton had remained in custody overnight and was not progressed as quickly as he could have been whilst in custody as there was no-one available to interview him. This is as a result of GMP policy on how people are progressed through custody. The Prisoner Processing Unit is not staffed overnight which leads to people being in custody longer than they should be and bringing GMP “up against the requirements of the Police and Criminal Evidence Act”. GMP cannot indicate how many people may have been detained in custody longer than they should have been under their new policy.
2. There was a lack of understanding amongst the custody staff and staff from other agencies as to the level of observations Mr Salton was on and why he was on those observations. It is important that everyone who has care of someone in custody understands what the observations have been, what they should be, when they are to be carried out, whether rousing is required and why the observations are set as they are – i.e. what the medical condition/ concern is.
3. When the deceased is visited and checked all such visits should be accurately recorded on the custody record.
4. Risk assessments carried out whilst in police custody should be recorded when they are done. If there are no changes to a risk assessment then this should be recorded and any rationale noted.
5. Handovers between Custody Sergeants were ineffective and there was no handover between the Civilian Detention Staff. Important information was missed or lost in translation. Proper handovers should take place as to a detained person’s condition, risk assessment, any medical condition, level of visits and other important matters.
6. The Prisoner Escort Form was incorrectly completed. The final Custody Sergeant should ensure that the transferring documentation is accurate.
7. There were no specific instructions to monitor Mr Salton whilst he was in the CCTV cell. The CCTV screen is situated furthest away from the desk where someone in the back office is more likely to be seated (next to the security controls) meaning that there is less likelihood of them “glancing” at the CCTV screen.
1. MEDACS should ensure that all staff are fully aware of the content of any MEDACS policies or protocols, where these can be located in the police station and if necessary receive any required training on the same (the Court heard that ████████ was not aware of the MEDACS Epilepsy Policy).
2. MEDACS should receive a verbal report from Custody Staff and as much information as possible as to the detained person’s medical condition. Even if they are solely to administer medication MEDACS staff should read any previous medical notes from the same stay in custody.
3. All staff are reminded of the need to record information on the MEDACS Assessment Form including completing a Care Plan. Such a form should be completed accurately including any negative answers to questions asked.
4. If a doctor or nurse is unable to complete a medical assessment or is not assessing an individual then this should be explained and any potentially misleading information should not be recorded.
1. Staff should be reminded of the levels of observation (cell checks) required on detained persons whilst in their custody.
2. Staff should be reminded that all cell checks should be accurately documented .
3. GEO AMEY should ensure that their staff have knowledge of and fully read any documentation available when collecting a detained person. This is especially true of any medical information and if there is a medical reason why someone is on a certain level / type of observation that this is replicated whilst in the custody of GEO AMEY.
” 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 GeoAmey PECS Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to complete prisoner transfer documentation accurately
Wider context from the report “1. During the course of the evidence I heard that Mr Salton had remained in custody overnight and was not progressed as quickly as he could have been whilst in custody as there was no-one available to interview him. This is as a result of GMP policy on how people are progressed through custody. The Prisoner Processing Unit is not staffed overnight which leads to people being in custody longer than they should be and bringing GMP “up against the requirements of the Police and Criminal Evidence Act”. GMP cannot indicate how many people may have been detained in custody longer than they should have been under their new policy.
2. There was a lack of understanding amongst the custody staff and staff from other agencies as to the level of observations Mr Salton was on and why he was on those observations. It is important that everyone who has care of someone in custody understands what the observations have been, what they should be, when they are to be carried out, whether rousing is required and why the observations are set as they are – i.e. what the medical condition/ concern is.
3. When the deceased is visited and checked all such visits should be accurately recorded on the custody record.
4. Risk assessments carried out whilst in police custody should be recorded when they are done. If there are no changes to a risk assessment then this should be recorded and any rationale noted.
5. Handovers between Custody Sergeants were ineffective and there was no handover between the Civilian Detention Staff. Important information was missed or lost in translation. Proper handovers should take place as to a detained person’s condition, risk assessment, any medical condition, level of visits and other important matters.
6. The Prisoner Escort Form was incorrectly completed . The final Custody Sergeant should ensure that the transferring documentation is accurate.
7. There were no specific instructions to monitor Mr Salton whilst he was in the CCTV cell. The CCTV screen is situated furthest away from the desk where someone in the back office is more likely to be seated (next to the security controls) meaning that there is less likelihood of them “glancing” at the CCTV screen.
1. MEDACS should ensure that all staff are fully aware of the content of any MEDACS policies or protocols, where these can be located in the police station and if necessary receive any required training on the same (the Court heard that ████████ was not aware of the MEDACS Epilepsy Policy).
2. MEDACS should receive a verbal report from Custody Staff and as much information as possible as to the detained person’s medical condition. Even if they are solely to administer medication MEDACS staff should read any previous medical notes from the same stay in custody.
3. All staff are reminded of the need to record information on the MEDACS Assessment Form including completing a Care Plan. Such a form should be completed accurately including any negative answers to questions asked.
4. If a doctor or nurse is unable to complete a medical assessment or is not assessing an individual then this should be explained and any potentially misleading information should not be recorded.
1. Staff should be reminded of the levels of observation (cell checks) required on detained persons whilst in their custody.
2. Staff should be reminded that all cell checks should be accurately documented.
3. GEO AMEY should ensure that their staff have knowledge of and fully read any documentation available when collecting a detained person. This is especially true of any medical information and if there is a medical reason why someone is on a certain level / type of observation that this is replicated whilst in the custody of GEO AMEY.
” 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 GeoAmey PECS Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to staff the Prisoner Processing Unit overnight
Wider context from the report “1. During the course of the evidence I heard that Mr Salton had remained in custody overnight and was not progressed as quickly as he could have been whilst in custody as there was no-one available to interview him. This is as a result of GMP policy on how people are progressed through custody. The Prisoner Processing Unit is not staffed overnight which leads to people being in custody longer than they should be and bringing GMP “up against the requirements of the Police and Criminal Evidence Act”. GMP cannot indicate how many people may have been detained in custody longer than they should have been under their new policy .
2. There was a lack of understanding amongst the custody staff and staff from other agencies as to the level of observations Mr Salton was on and why he was on those observations. It is important that everyone who has care of someone in custody understands what the observations have been, what they should be, when they are to be carried out, whether rousing is required and why the observations are set as they are – i.e. what the medical condition/ concern is.
3. When the deceased is visited and checked all such visits should be accurately recorded on the custody record.
4. Risk assessments carried out whilst in police custody should be recorded when they are done. If there are no changes to a risk assessment then this should be recorded and any rationale noted.
5. Handovers between Custody Sergeants were ineffective and there was no handover between the Civilian Detention Staff. Important information was missed or lost in translation. Proper handovers should take place as to a detained person’s condition, risk assessment, any medical condition, level of visits and other important matters.
6. The Prisoner Escort Form was incorrectly completed. The final Custody Sergeant should ensure that the transferring documentation is accurate.
7. There were no specific instructions to monitor Mr Salton whilst he was in the CCTV cell. The CCTV screen is situated furthest away from the desk where someone in the back office is more likely to be seated (next to the security controls) meaning that there is less likelihood of them “glancing” at the CCTV screen.
1. MEDACS should ensure that all staff are fully aware of the content of any MEDACS policies or protocols, where these can be located in the police station and if necessary receive any required training on the same (the Court heard that ████████ was not aware of the MEDACS Epilepsy Policy).
2. MEDACS should receive a verbal report from Custody Staff and as much information as possible as to the detained person’s medical condition. Even if they are solely to administer medication MEDACS staff should read any previous medical notes from the same stay in custody.
3. All staff are reminded of the need to record information on the MEDACS Assessment Form including completing a Care Plan. Such a form should be completed accurately including any negative answers to questions asked.
4. If a doctor or nurse is unable to complete a medical assessment or is not assessing an individual then this should be explained and any potentially misleading information should not be recorded.
1. Staff should be reminded of the levels of observation (cell checks) required on detained persons whilst in their custody.
2. Staff should be reminded that all cell checks should be accurately documented.
3. GEO AMEY should ensure that their staff have knowledge of and fully read any documentation available when collecting a detained person. This is especially true of any medical information and if there is a medical reason why someone is on a certain level / type of observation that this is replicated whilst in the custody of GEO AMEY.
” 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 GeoAmey PECS Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of staff knowledge of MEDACS policies and protocols
Wider context from the report “1. During the course of the evidence I heard that Mr Salton had remained in custody overnight and was not progressed as quickly as he could have been whilst in custody as there was no-one available to interview him. This is as a result of GMP policy on how people are progressed through custody. The Prisoner Processing Unit is not staffed overnight which leads to people being in custody longer than they should be and bringing GMP “up against the requirements of the Police and Criminal Evidence Act”. GMP cannot indicate how many people may have been detained in custody longer than they should have been under their new policy.
2. There was a lack of understanding amongst the custody staff and staff from other agencies as to the level of observations Mr Salton was on and why he was on those observations. It is important that everyone who has care of someone in custody understands what the observations have been, what they should be, when they are to be carried out, whether rousing is required and why the observations are set as they are – i.e. what the medical condition/ concern is.
3. When the deceased is visited and checked all such visits should be accurately recorded on the custody record.
4. Risk assessments carried out whilst in police custody should be recorded when they are done. If there are no changes to a risk assessment then this should be recorded and any rationale noted.
5. Handovers between Custody Sergeants were ineffective and there was no handover between the Civilian Detention Staff. Important information was missed or lost in translation. Proper handovers should take place as to a detained person’s condition, risk assessment, any medical condition, level of visits and other important matters.
6. The Prisoner Escort Form was incorrectly completed. The final Custody Sergeant should ensure that the transferring documentation is accurate.
7. There were no specific instructions to monitor Mr Salton whilst he was in the CCTV cell. The CCTV screen is situated furthest away from the desk where someone in the back office is more likely to be seated (next to the security controls) meaning that there is less likelihood of them “glancing” at the CCTV screen.
1. MEDACS should ensure that all staff are fully aware of the content of any MEDACS policies or protocols , where these can be located in the police station and if necessary receive any required training on the same (the Court heard that ████████ was not aware of the MEDACS Epilepsy Policy ).
2. MEDACS should receive a verbal report from Custody Staff and as much information as possible as to the detained person’s medical condition. Even if they are solely to administer medication MEDACS staff should read any previous medical notes from the same stay in custody.
3. All staff are reminded of the need to record information on the MEDACS Assessment Form including completing a Care Plan. Such a form should be completed accurately including any negative answers to questions asked.
4. If a doctor or nurse is unable to complete a medical assessment or is not assessing an individual then this should be explained and any potentially misleading information should not be recorded.
1. Staff should be reminded of the levels of observation (cell checks) required on detained persons whilst in their custody.
2. Staff should be reminded that all cell checks should be accurately documented.
3. GEO AMEY should ensure that their staff have knowledge of and fully read any documentation available when collecting a detained person. This is especially true of any medical information and if there is a medical reason why someone is on a certain level / type of observation that this is replicated whilst in the custody of GEO AMEY.
” 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 GeoAmey PECS Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to transfer and replicate medical observation information during GEO AMEY custody
Wider context from the report “1. During the course of the evidence I heard that Mr Salton had remained in custody overnight and was not progressed as quickly as he could have been whilst in custody as there was no-one available to interview him. This is as a result of GMP policy on how people are progressed through custody. The Prisoner Processing Unit is not staffed overnight which leads to people being in custody longer than they should be and bringing GMP “up against the requirements of the Police and Criminal Evidence Act”. GMP cannot indicate how many people may have been detained in custody longer than they should have been under their new policy.
2. There was a lack of understanding amongst the custody staff and staff from other agencies as to the level of observations Mr Salton was on and why he was on those observations. It is important that everyone who has care of someone in custody understands what the observations have been, what they should be, when they are to be carried out, whether rousing is required and why the observations are set as they are – i.e. what the medical condition/ concern is.
3. When the deceased is visited and checked all such visits should be accurately recorded on the custody record.
4. Risk assessments carried out whilst in police custody should be recorded when they are done. If there are no changes to a risk assessment then this should be recorded and any rationale noted.
5. Handovers between Custody Sergeants were ineffective and there was no handover between the Civilian Detention Staff. Important information was missed or lost in translation. Proper handovers should take place as to a detained person’s condition, risk assessment, any medical condition, level of visits and other important matters.
6. The Prisoner Escort Form was incorrectly completed. The final Custody Sergeant should ensure that the transferring documentation is accurate.
7. There were no specific instructions to monitor Mr Salton whilst he was in the CCTV cell. The CCTV screen is situated furthest away from the desk where someone in the back office is more likely to be seated (next to the security controls) meaning that there is less likelihood of them “glancing” at the CCTV screen.
1. MEDACS should ensure that all staff are fully aware of the content of any MEDACS policies or protocols, where these can be located in the police station and if necessary receive any required training on the same (the Court heard that ████████ was not aware of the MEDACS Epilepsy Policy).
2. MEDACS should receive a verbal report from Custody Staff and as much information as possible as to the detained person’s medical condition. Even if they are solely to administer medication MEDACS staff should read any previous medical notes from the same stay in custody.
3. All staff are reminded of the need to record information on the MEDACS Assessment Form including completing a Care Plan. Such a form should be completed accurately including any negative answers to questions asked.
4. If a doctor or nurse is unable to complete a medical assessment or is not assessing an individual then this should be explained and any potentially misleading information should not be recorded.
1. Staff should be reminded of the levels of observation (cell checks) required on detained persons whilst in their custody.
2. Staff should be reminded that all cell checks should be accurately documented.
3. GEO AMEY should ensure that their staff have knowledge of and fully read any documentation available when collecting a detained person . This is especially true of any medical information and if there is a medical reason why someone is on a certain level / type of observation that this is replicated whilst in the custody of GEO AMEY .
” 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 GeoAmey PECS Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of specific instructions and effective positioning for CCTV cell monitoring
Wider context from the report “1. During the course of the evidence I heard that Mr Salton had remained in custody overnight and was not progressed as quickly as he could have been whilst in custody as there was no-one available to interview him. This is as a result of GMP policy on how people are progressed through custody. The Prisoner Processing Unit is not staffed overnight which leads to people being in custody longer than they should be and bringing GMP “up against the requirements of the Police and Criminal Evidence Act”. GMP cannot indicate how many people may have been detained in custody longer than they should have been under their new policy.
2. There was a lack of understanding amongst the custody staff and staff from other agencies as to the level of observations Mr Salton was on and why he was on those observations. It is important that everyone who has care of someone in custody understands what the observations have been, what they should be, when they are to be carried out, whether rousing is required and why the observations are set as they are – i.e. what the medical condition/ concern is.
3. When the deceased is visited and checked all such visits should be accurately recorded on the custody record.
4. Risk assessments carried out whilst in police custody should be recorded when they are done. If there are no changes to a risk assessment then this should be recorded and any rationale noted.
5. Handovers between Custody Sergeants were ineffective and there was no handover between the Civilian Detention Staff. Important information was missed or lost in translation. Proper handovers should take place as to a detained person’s condition, risk assessment, any medical condition, level of visits and other important matters.
6. The Prisoner Escort Form was incorrectly completed. The final Custody Sergeant should ensure that the transferring documentation is accurate.
7. There were no specific instructions to monitor Mr Salton whilst he was in the CCTV cell . The CCTV screen is situated furthest away from the desk where someone in the back office is more likely to be seated (next to the security controls) meaning that there is less likelihood of them “glancing” at the CCTV screen .
1. MEDACS should ensure that all staff are fully aware of the content of any MEDACS policies or protocols, where these can be located in the police station and if necessary receive any required training on the same (the Court heard that ████████ was not aware of the MEDACS Epilepsy Policy).
2. MEDACS should receive a verbal report from Custody Staff and as much information as possible as to the detained person’s medical condition. Even if they are solely to administer medication MEDACS staff should read any previous medical notes from the same stay in custody.
3. All staff are reminded of the need to record information on the MEDACS Assessment Form including completing a Care Plan. Such a form should be completed accurately including any negative answers to questions asked.
4. If a doctor or nurse is unable to complete a medical assessment or is not assessing an individual then this should be explained and any potentially misleading information should not be recorded.
1. Staff should be reminded of the levels of observation (cell checks) required on detained persons whilst in their custody.
2. Staff should be reminded that all cell checks should be accurately documented.
3. GEO AMEY should ensure that their staff have knowledge of and fully read any documentation available when collecting a detained person. This is especially true of any medical information and if there is a medical reason why someone is on a certain level / type of observation that this is replicated whilst in the custody of GEO AMEY.
” 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 GeoAmey PECS Limited; that does not assign responsibility.
PFD Monitor interpretation Ineffective or absent handovers between custody staff
Wider context from the report “1. During the course of the evidence I heard that Mr Salton had remained in custody overnight and was not progressed as quickly as he could have been whilst in custody as there was no-one available to interview him. This is as a result of GMP policy on how people are progressed through custody. The Prisoner Processing Unit is not staffed overnight which leads to people being in custody longer than they should be and bringing GMP “up against the requirements of the Police and Criminal Evidence Act”. GMP cannot indicate how many people may have been detained in custody longer than they should have been under their new policy.
2. There was a lack of understanding amongst the custody staff and staff from other agencies as to the level of observations Mr Salton was on and why he was on those observations. It is important that everyone who has care of someone in custody understands what the observations have been, what they should be, when they are to be carried out, whether rousing is required and why the observations are set as they are – i.e. what the medical condition/ concern is.
3. When the deceased is visited and checked all such visits should be accurately recorded on the custody record.
4. Risk assessments carried out whilst in police custody should be recorded when they are done. If there are no changes to a risk assessment then this should be recorded and any rationale noted.
5. Handovers between Custody Sergeants were ineffective and there was no handover between the Civilian Detention Staff . Important information was missed or lost in translation . Proper handovers should take place as to a detained person’s condition, risk assessment, any medical condition, level of visits and other important matters.
6. The Prisoner Escort Form was incorrectly completed. The final Custody Sergeant should ensure that the transferring documentation is accurate.
7. There were no specific instructions to monitor Mr Salton whilst he was in the CCTV cell. The CCTV screen is situated furthest away from the desk where someone in the back office is more likely to be seated (next to the security controls) meaning that there is less likelihood of them “glancing” at the CCTV screen.
1. MEDACS should ensure that all staff are fully aware of the content of any MEDACS policies or protocols, where these can be located in the police station and if necessary receive any required training on the same (the Court heard that ████████ was not aware of the MEDACS Epilepsy Policy).
2. MEDACS should receive a verbal report from Custody Staff and as much information as possible as to the detained person’s medical condition. Even if they are solely to administer medication MEDACS staff should read any previous medical notes from the same stay in custody.
3. All staff are reminded of the need to record information on the MEDACS Assessment Form including completing a Care Plan. Such a form should be completed accurately including any negative answers to questions asked.
4. If a doctor or nurse is unable to complete a medical assessment or is not assessing an individual then this should be explained and any potentially misleading information should not be recorded.
1. Staff should be reminded of the levels of observation (cell checks) required on detained persons whilst in their custody.
2. Staff should be reminded that all cell checks should be accurately documented.
3. GEO AMEY should ensure that their staff have knowledge of and fully read any documentation available when collecting a detained person. This is especially true of any medical information and if there is a medical reason why someone is on a certain level / type of observation that this is replicated whilst in the custody of GEO AMEY.
” 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 GeoAmey PECS Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to accurately record custody visits and checks
Wider context from the report “1. During the course of the evidence I heard that Mr Salton had remained in custody overnight and was not progressed as quickly as he could have been whilst in custody as there was no-one available to interview him. This is as a result of GMP policy on how people are progressed through custody. The Prisoner Processing Unit is not staffed overnight which leads to people being in custody longer than they should be and bringing GMP “up against the requirements of the Police and Criminal Evidence Act”. GMP cannot indicate how many people may have been detained in custody longer than they should have been under their new policy.
2. There was a lack of understanding amongst the custody staff and staff from other agencies as to the level of observations Mr Salton was on and why he was on those observations. It is important that everyone who has care of someone in custody understands what the observations have been, what they should be, when they are to be carried out, whether rousing is required and why the observations are set as they are – i.e. what the medical condition/ concern is.
3. When the deceased is visited and checked all such visits should be accurately recorded on the custody record .
4. Risk assessments carried out whilst in police custody should be recorded when they are done. If there are no changes to a risk assessment then this should be recorded and any rationale noted.
5. Handovers between Custody Sergeants were ineffective and there was no handover between the Civilian Detention Staff. Important information was missed or lost in translation. Proper handovers should take place as to a detained person’s condition, risk assessment, any medical condition, level of visits and other important matters.
6. The Prisoner Escort Form was incorrectly completed. The final Custody Sergeant should ensure that the transferring documentation is accurate.
7. There were no specific instructions to monitor Mr Salton whilst he was in the CCTV cell. The CCTV screen is situated furthest away from the desk where someone in the back office is more likely to be seated (next to the security controls) meaning that there is less likelihood of them “glancing” at the CCTV screen.
1. MEDACS should ensure that all staff are fully aware of the content of any MEDACS policies or protocols, where these can be located in the police station and if necessary receive any required training on the same (the Court heard that ████████ was not aware of the MEDACS Epilepsy Policy).
2. MEDACS should receive a verbal report from Custody Staff and as much information as possible as to the detained person’s medical condition. Even if they are solely to administer medication MEDACS staff should read any previous medical notes from the same stay in custody.
3. All staff are reminded of the need to record information on the MEDACS Assessment Form including completing a Care Plan. Such a form should be completed accurately including any negative answers to questions asked.
4. If a doctor or nurse is unable to complete a medical assessment or is not assessing an individual then this should be explained and any potentially misleading information should not be recorded.
1. Staff should be reminded of the levels of observation (cell checks) required on detained persons whilst in their custody.
2. Staff should be reminded that all cell checks should be accurately documented.
3. GEO AMEY should ensure that their staff have knowledge of and fully read any documentation available when collecting a detained person. This is especially true of any medical information and if there is a medical reason why someone is on a certain level / type of observation that this is replicated whilst in the custody of GEO AMEY.
” 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 GeoAmey PECS Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to record custody risk assessments and rationale for unchanged assessments
Wider context from the report “1. During the course of the evidence I heard that Mr Salton had remained in custody overnight and was not progressed as quickly as he could have been whilst in custody as there was no-one available to interview him. This is as a result of GMP policy on how people are progressed through custody. The Prisoner Processing Unit is not staffed overnight which leads to people being in custody longer than they should be and bringing GMP “up against the requirements of the Police and Criminal Evidence Act”. GMP cannot indicate how many people may have been detained in custody longer than they should have been under their new policy.
2. There was a lack of understanding amongst the custody staff and staff from other agencies as to the level of observations Mr Salton was on and why he was on those observations. It is important that everyone who has care of someone in custody understands what the observations have been, what they should be, when they are to be carried out, whether rousing is required and why the observations are set as they are – i.e. what the medical condition/ concern is.
3. When the deceased is visited and checked all such visits should be accurately recorded on the custody record.
4. Risk assessments carried out whilst in police custody should be recorded when they are done . If there are no changes to a risk assessment then this should be recorded and any rationale noted .
5. Handovers between Custody Sergeants were ineffective and there was no handover between the Civilian Detention Staff. Important information was missed or lost in translation. Proper handovers should take place as to a detained person’s condition, risk assessment, any medical condition, level of visits and other important matters.
6. The Prisoner Escort Form was incorrectly completed. The final Custody Sergeant should ensure that the transferring documentation is accurate.
7. There were no specific instructions to monitor Mr Salton whilst he was in the CCTV cell. The CCTV screen is situated furthest away from the desk where someone in the back office is more likely to be seated (next to the security controls) meaning that there is less likelihood of them “glancing” at the CCTV screen.
1. MEDACS should ensure that all staff are fully aware of the content of any MEDACS policies or protocols, where these can be located in the police station and if necessary receive any required training on the same (the Court heard that ████████ was not aware of the MEDACS Epilepsy Policy).
2. MEDACS should receive a verbal report from Custody Staff and as much information as possible as to the detained person’s medical condition. Even if they are solely to administer medication MEDACS staff should read any previous medical notes from the same stay in custody.
3. All staff are reminded of the need to record information on the MEDACS Assessment Form including completing a Care Plan. Such a form should be completed accurately including any negative answers to questions asked.
4. If a doctor or nurse is unable to complete a medical assessment or is not assessing an individual then this should be explained and any potentially misleading information should not be recorded.
1. Staff should be reminded of the levels of observation (cell checks) required on detained persons whilst in their custody.
2. Staff should be reminded that all cell checks should be accurately documented.
3. GEO AMEY should ensure that their staff have knowledge of and fully read any documentation available when collecting a detained person. This is especially true of any medical information and if there is a medical reason why someone is on a certain level / type of observation that this is replicated whilst in the custody of GEO AMEY.
” Open source report
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations