10 Mar 2026 Surendrakumar Patel · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 8 Failure to consider and advocate for family contact View source Delays in full medical assessment by a senior healthcare professional View source Failure to inform Next of Kin of a prisoner’s decision to refuse food or fluids View source Lack of prison staff awareness of the HMP Hewell food refusal policy View source Lack of healthcare staff awareness of the food refusal policy View source Failure to recognise when mental capacity assessment is required after food refusal begins View source Failure to ask the prisoner whether food refusal information should be shared View source Failure to consider hospital transfer for prisoners severely weakened by weight loss View source See 5 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.
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AI-generated summary
Surendrakumar Patel · 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
Surendrakumar Patel died at Alexandra Hospital, Redditch, on 31 October 2024 after collapsing with a lower respiratory tract infection, with self-neglect through malnutrition contributing to his death. While on remand at HMP Hewell, he stopped eating, expressed that he no longer wished to live, lost weight, and developed acute kidney injury. The report identified concerns about healthcare staff’s failure to recognise the need for a timely mental capacity assessment, consider hospital transfer and expedited senior medical and psychiatric assessment, and consider family contact; prison staff also lacked awareness of procedures for informing or consulting next of kin about food refusal.
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 Government Legal Department; that does not assign responsibility.
PFD Monitor interpretation Failure to consider and advocate for family contact
Wider context from the report “1. Healthcare staff (MPFT and PPG) lacked awareness of the food refusal policy:
a. Failure to recognise that a mental capacity assessment was required as soon as food refusal began
b. Failure to consider hospital transfer for prisoners severely weakened by weight loss
c. Failure to expedite full medical assessment by a senior healthcare professional, including psychiatric assessment where physical health posed a risk to survival
d. Failure to consider and advocate for family contact
2. Prison staff lacked awareness of HMP Hewell food refusal policy, including:
• Not informing Next of Kin of the prisoner’s decision to refuse food/fluids
• Not asking the prisoner whether such information should be shared
” 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 Government Legal Department; that does not assign responsibility.
PFD Monitor interpretation Delays in full medical assessment by a senior healthcare professional
Wider context from the report “1. Healthcare staff (MPFT and PPG) lacked awareness of the food refusal policy:
a. Failure to recognise that a mental capacity assessment was required as soon as food refusal began
b. Failure to consider hospital transfer for prisoners severely weakened by weight loss
c. Failure to expedite full medical assessment by a senior healthcare professional, including psychiatric assessment where physical health posed a risk to survival
d. Failure to consider and advocate for family contact
2. Prison staff lacked awareness of HMP Hewell food refusal policy, including:
• Not informing Next of Kin of the prisoner’s decision to refuse food/fluids
• Not asking the prisoner whether such information should be shared
” 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 Government Legal Department; that does not assign responsibility.
PFD Monitor interpretation Failure to inform Next of Kin of a prisoner’s decision to refuse food or fluids
Wider context from the report “1. Healthcare staff (MPFT and PPG) lacked awareness of the food refusal policy:
a. Failure to recognise that a mental capacity assessment was required as soon as food refusal began
b. Failure to consider hospital transfer for prisoners severely weakened by weight loss
c. Failure to expedite full medical assessment by a senior healthcare professional, including psychiatric assessment where physical health posed a risk to survival
d. Failure to consider and advocate for family contact
2. Prison staff lacked awareness of HMP Hewell food refusal policy, including:
• Not informing Next of Kin of the prisoner’s decision to refuse food/fluids
• Not asking the prisoner whether such information should be shared
” 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 Government Legal Department; that does not assign responsibility.
PFD Monitor interpretation Lack of prison staff awareness of the HMP Hewell food refusal policy
Wider context from the report “1. Healthcare staff (MPFT and PPG) lacked awareness of the food refusal policy:
a. Failure to recognise that a mental capacity assessment was required as soon as food refusal began
b. Failure to consider hospital transfer for prisoners severely weakened by weight loss
c. Failure to expedite full medical assessment by a senior healthcare professional, including psychiatric assessment where physical health posed a risk to survival
d. Failure to consider and advocate for family contact
2. Prison staff lacked awareness of HMP Hewell food refusal policy , including:
• Not informing Next of Kin of the prisoner’s decision to refuse food/fluids
• Not asking the prisoner whether such information should be shared
” 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 Government Legal Department; that does not assign responsibility.
PFD Monitor interpretation Lack of healthcare staff awareness of the food refusal policy
Wider context from the report “1. Healthcare staff (MPFT and PPG) lacked awareness of the food refusal policy :
a. Failure to recognise that a mental capacity assessment was required as soon as food refusal began
b. Failure to consider hospital transfer for prisoners severely weakened by weight loss
c. Failure to expedite full medical assessment by a senior healthcare professional, including psychiatric assessment where physical health posed a risk to survival
d. Failure to consider and advocate for family contact
2. Prison staff lacked awareness of HMP Hewell food refusal policy, including:
• Not informing Next of Kin of the prisoner’s decision to refuse food/fluids
• Not asking the prisoner whether such information should be shared
” 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 Government Legal Department; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise when mental capacity assessment is required after food refusal begins
Wider context from the report “1. Healthcare staff (MPFT and PPG) lacked awareness of the food refusal policy:
a. Failure to recognise that a mental capacity assessment was required as soon as food refusal began
b. Failure to consider hospital transfer for prisoners severely weakened by weight loss
c. Failure to expedite full medical assessment by a senior healthcare professional, including psychiatric assessment where physical health posed a risk to survival
d. Failure to consider and advocate for family contact
2. Prison staff lacked awareness of HMP Hewell food refusal policy, including:
• Not informing Next of Kin of the prisoner’s decision to refuse food/fluids
• Not asking the prisoner whether such information should be shared
” 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 Government Legal Department; that does not assign responsibility.
PFD Monitor interpretation Failure to ask the prisoner whether food refusal information should be shared
Wider context from the report “1. Healthcare staff (MPFT and PPG) lacked awareness of the food refusal policy:
a. Failure to recognise that a mental capacity assessment was required as soon as food refusal began
b. Failure to consider hospital transfer for prisoners severely weakened by weight loss
c. Failure to expedite full medical assessment by a senior healthcare professional, including psychiatric assessment where physical health posed a risk to survival
d. Failure to consider and advocate for family contact
2. Prison staff lacked awareness of HMP Hewell food refusal policy, including:
• Not informing Next of Kin of the prisoner’s decision to refuse food/fluids
• Not asking the prisoner whether such information should be shared
” 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 Government Legal Department; that does not assign responsibility.
PFD Monitor interpretation Failure to consider hospital transfer for prisoners severely weakened by weight loss
Wider context from the report “1. Healthcare staff (MPFT and PPG) lacked awareness of the food refusal policy:
a. Failure to recognise that a mental capacity assessment was required as soon as food refusal began
b. Failure to consider hospital transfer for prisoners severely weakened by weight loss
c. Failure to expedite full medical assessment by a senior healthcare professional, including psychiatric assessment where physical health posed a risk to survival
d. Failure to consider and advocate for family contact
2. Prison staff lacked awareness of HMP Hewell food refusal policy, including:
• Not informing Next of Kin of the prisoner’s decision to refuse food/fluids
• Not asking the prisoner whether such information should be shared
” Open source report
20 Sep 2022 Gary McDonald · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 1 Failure to routinely follow up discrepancies between disclosed mental health history and community GP records View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Gary McDonald · 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
Gary McDonald was found deceased in his cell at HMP Hewell after spending nearly four months on remand awaiting trial; the inquest concluded that he died as a result of suicide. The principal concern was that, despite prison healthcare receiving records showing a history of depression and two previous overdoses, including one seven months earlier, there was no system to follow up discrepancies between a prisoner's disclosed mental health history and community GP records.
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 Government Legal Department; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely follow up discrepancies between disclosed mental health history and community GP records
Wider context from the report “5) I am concerned that there is currently no system in place at HMP Hewell to follow up with a prisoner any discrepancy between the mental health history which he has disclosed on arrival at the prison, and that revealed in his community GP records . Experience suggests that a prisoner with a recorded history of mental health issues, particularly one which includes a recent episode of attempted suicide or self-harm through overdose, may be at his most vulnerable during his first days and weeks at a prison, and having been reluctant to disclose such issues for any number of reasons ( e.g. fear, embarrassment ), may be reassured to be told that healthcare staff at the prison are aware of that history and can provide confidential support. In my view, without routine follow-up in such cases, there remains a significant risk that a prisoner’s recent significant history of suicide or self-harm may be overlooked in those important early days and weeks in prison , and that such prisoners will therefore be at an increased risk of further episodes of attempted suicide during that period.
” Open source report
Concerns raised 4 Lack of written instructions for conducting welfare checks View source Unclear allocation of task-list responsibilities during night-shift agency cover View source Gaps in communication of crucial substance-misuse and Naloxone information to Approved Premises View source Lack of auditing of task-list completion and welfare-check performance View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Jamie Lee Bennett · 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
Jamie Lee Bennett, who had been abstinent from drugs and methadone for approximately eight months, was found unresponsive in his room at Norfolk Park Bail Hostel on 2 May 2020 and was pronounced deceased by paramedics. The report identified concerns about incomplete sharing of his substance-misuse and Naloxone information, reduced support after release, unclear responsibilities and inadequate training and auditing for welfare checks, and a delay in calling emergency services.
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 Government Legal Department; that does not assign responsibility.
PFD Monitor interpretation Lack of written instructions for conducting welfare checks
Wider context from the report “The evidence was unclear as to who will carry out actions on the task lists on a night shift when a Sodexo worker was replaced by agency staff. There is no audit process in place to ensure staff are carrying out tasks in accordance with the lists issued
There are no written instructions on how to conduct welfare checks . There is no audit process in place to ensure staff are conducting welfare checks appropriately
It is my opinion there is a risk that future deaths may occur unless there are:
• Clear, written instructions on how to conduct welfare checks
• Clarity around which member of staff will be responsible for which task list, particularly on a night shift when a Sodexo worker is replaced by agency staff
• An audit process put in place to ensure staff are carrying out tasks in accordance with the lists issued and in particular are conducting welfare checks appropriately
” 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 Government Legal Department; that does not assign responsibility.
PFD Monitor interpretation Unclear allocation of task-list responsibilities during night-shift agency cover
Wider context from the report “The evidence was unclear as to who will carry out actions on the task lists on a night shift when a Sodexo worker was replaced by agency staff. There is no audit process in place to ensure staff are carrying out tasks in accordance with the lists issued
There are no written instructions on how to conduct welfare checks. There is no audit process in place to ensure staff are conducting welfare checks appropriately
It is my opinion there is a risk that future deaths may occur unless there are:
• Clear, written instructions on how to conduct welfare checks
• Clarity around which member of staff will be responsible for which task list, particularly on a night shift when a Sodexo worker is replaced by agency staff
• An audit process put in place to ensure staff are carrying out tasks in accordance with the lists issued and in particular are conducting welfare checks appropriately
” 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 Government Legal Department; that does not assign responsibility.
PFD Monitor interpretation Gaps in communication of crucial substance-misuse and Naloxone information to Approved Premises
Wider context from the report “There were gaps in the information provided by HMP Moorlands to Norfolk Park Bail Hostel, in particular his history of substance misuse and that Jamie had refused Naloxone. The Court heard evidence that information sharing with third parties is in line with national guidelines, but also that there should have been another report by the offender management services that would have been more detailed and would have given this information to Norfolk Park . I do feel that if Norfolk Park Bail Hostel had that information, they would have been in a better position to support Jamie during those first crucial 48 hours and that may have reduced the risk of him using substances and dying
It is my view there should be a process by which crucial information about a patient is communicated to the Approved Premise , specifically substance misuse history, any substance misuse work, any detox or re-toxification processes undertaken, and whether the patient has accepted or refused Naloxone and any community drugs services referral. It is my view this will assist the Approved Premise to determine the level of support to be offered to a resident, especially those that are released on a Friday and will have limited support from anywhere other than an Approved Premise during the first 48 hours
It is my opinion there is a risk that future deaths may occur unless such a process is developed
” 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 Government Legal Department; that does not assign responsibility.
PFD Monitor interpretation Lack of auditing of task-list completion and welfare-check performance
Wider context from the report “The evidence was unclear as to who will carry out actions on the task lists on a night shift when a Sodexo worker was replaced by agency staff. There is no audit process in place to ensure staff are carrying out tasks in accordance with the lists issued
There are no written instructions on how to conduct welfare checks. There is no audit process in place to ensure staff are conducting welfare checks appropriately
It is my opinion there is a risk that future deaths may occur unless there are:
• Clear, written instructions on how to conduct welfare checks
• Clarity around which member of staff will be responsible for which task list, particularly on a night shift when a Sodexo worker is replaced by agency staff
• An audit process put in place to ensure staff are carrying out tasks in accordance with the lists issued and in particular are conducting welfare checks appropriately
” Open source report
24 Jan 2022 Idris HABIB · Prevention of Future Deaths report Mid Kent and Medway
View report summary
Concerns raised 4 Failure to align local roll-check policy with entry-level officer training View source Failure to document welfare checks as having taken place View source Failure to ensure welfare checks are conducted without being overlooked View source Failure to remove previous occupants' medication from cells View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Idris HABIB · 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
Idris Habib was found suspended in his cell at HMP Swaleside after incidents involving self-harm, a cell fire and statements that he was being bullied and wanted to kill himself. The inquest concluded that he took his own life by hanging, although his intention was unclear. Concerns included medication from a previous occupant being found in the cell, a disconnect between local policy and training on roll checks, and the need to ensure welfare checks were conducted and documented.
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 Government Legal Department; that does not assign responsibility.
PFD Monitor interpretation Failure to align local roll-check policy with entry-level officer training
Wider context from the report “(2) There was a disconnect between HMP Swaleside's local policy and the Prison Officer Entry Level Training in respect of roll checks
” 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 Government Legal Department; that does not assign responsibility.
PFD Monitor interpretation Failure to document welfare checks as having taken place
Wider context from the report “(3) That measures put in place following Mr. Habib's death to ensure welfare checks are conducted are not overlooked and are documented as having taken place
” 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 Government Legal Department; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure welfare checks are conducted without being overlooked
Wider context from the report “(3) That measures put in place following Mr. Habib's death to ensure welfare checks are conducted are not overlooked and are documented as having taken place
” 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 Government Legal Department; that does not assign responsibility.
PFD Monitor interpretation Failure to remove previous occupants' medication from cells
Wider context from the report “(1) Medication from the previous occupant of cell B1-18 was found in the cell following the death of Mr Habib
” Open source report
Concerns raised 1 Inadequate control of access to novel psychoactive substances within the prison View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Luke Morris Jones · 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
Luke Morris Jones, a prisoner at HMP Berwyn, was found unresponsive after smoking a novel psychoactive substance and died on 31 March 2018 despite medical intervention. The report identified concerns about the accessibility and continuing availability of novel psychoactive substances in the prison and the associated risks to health.
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 Government Legal Department; that does not assign responsibility.
PFD Monitor interpretation Inadequate control of access to novel psychoactive substances within the prison
Wider context from the report “The report of the Prisons and Probation Ombudsman highlighted that there were concerns regarding the accessibility of drugs within HMP Berwyn and notwithstanding that certain measures had been taken at HMP Berwyn (namely in relation to the installation of a Rapiscan to test some of the incoming mail), evidence at the inquest confirmed that the continuing availability and use of novel psychoactive substances .
By way of example, the evidence of the prison GP indicated that at least one instance of a prisoner being intoxicated was reported to him each day which he worked and as a result I consider it highly probable that the combination of the accessibility of NPS and the significant risks which they pose to health will be the cause of future deaths at the prison.
” Open source report
7 Apr 2016 Matthew Colin SARGENT · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 4 Failure to inform Healthcare staff when prisoners arrive with an ACCT history View source Failure to review available historical prisoner information at initial presentation View source Lack of meaningful engagement between Personal Officers and individual prisoners View source Failure to supply Prisoner Escort Records to Healthcare staff at reception View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Matthew Colin SARGENT · 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
Matthew Colin SARGENT was a serving prisoner who died in his cell at some time between 25 and 26 September 2014. The jury concluded that he committed suicide and raised concerns about the systematic, accurate and clear sharing of historical and current information between prison and healthcare departments.
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 Government Legal Department; that does not assign responsibility.
PFD Monitor interpretation Failure to inform Healthcare staff when prisoners arrive with an ACCT history
Wider context from the report “(3) There was a concern that Healthcare staff were not made aware of prisoners who arrive with an ACCT history and it was suggested that Healthcare should be informed in all cases where a prisoner arrives at reception with an ACCT history so that there is a continued sharing of pertinent information.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Government Legal Department; that does not assign responsibility.
PFD Monitor interpretation Failure to review available historical prisoner information at initial presentation
Wider context from the report “(2) There was a concern that historical information which was available to Officers and Healthcare staff was not reviewed when the prisoner first presented at the prison and it was suggested that it would be beneficial if there was an instruction that any member of staff dealing with a prisoner who had access to historical information should make some enquiry as to that historical information so as to inform them of both the present and past 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 Government Legal Department; that does not assign responsibility.
PFD Monitor interpretation Lack of meaningful engagement between Personal Officers and individual prisoners
Wider context from the report “(1) The Personal Officer of Mr Sargent appeared to have had little to do with him . It was suggested that there should regular meetings between Personal Officers and individual prisoners so that a more indepth knowledge of individual prisoners could be obtained as shared.
” 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 Government Legal Department; that does not assign responsibility.
PFD Monitor interpretation Failure to supply Prisoner Escort Records to Healthcare staff at reception
Wider context from the report “(4) There was a concern that the Prisoner Escort Record (highlighting concerns and risks) was not supplied to the Healthcare Department and nurses at reception . It was suggested that this should be an imperative requirement for the further sharing of relevant information.
” Open source report
Concerns raised 5 Absence of a mechanism notifying local police when a person with a foreign murder conviction resides in their area View source Failure to ensure police awareness and protective conditions when individuals with foreign murder convictions enter the UK View source Exclusion of foreign murder convictions from the Notification Order framework View source Ineligibility of individuals with foreign murder convictions for a Violent Offender Order where the specified-offence risk threshold is not met View source Failure of the Central Authority to identify UK nationals serving sentences for serious crimes in EU prisons under the non-retrospective notification system View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Maria Christina Stubbings · 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
Maria Christina Stubbings was murdered in December 2008 by a man who had previously served a life sentence in Germany for murder and had been arrested for assaulting her. The principal concerns relate to gaps in the identification, notification, monitoring and control of people with serious foreign convictions entering or residing in the UK.
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 Government Legal Department; that does not assign responsibility.
PFD Monitor interpretation Absence of a mechanism notifying local police when a person with a foreign murder conviction resides in their area
Wider context from the report “Notwithstanding the changes that have occurred (i) enabling a Violent Offender Order to be made in relation to someone who has a conviction for murder (including murder abroad) in May 2014 and (ii) the EU Directive which requires EU member states to notify the UK of foreign convictions of UK Nationals, at the time of conviction (as opposed to later than this which occurred in the ████████ case) and (iii) the electronic system now in place at the Central Authority – it seems that there are further opportunities that might be considered which would reduce the likelihood of another individual (with a murder conviction like ████████) entering the UK without conditions and without any police force being made aware of that person’s existence, until arrested for different offence.
I ask the Home Office/MoJ to give consideration to further steps that could be taken to address the issues, including those detailed below. In making the suggestion below it is recognised that the issues are complex.
(i) The Central Authority needs to be notified now of all EU nationals currently serving a sentence for serious crimes such as murder in those countries. We understand the new notification system which obliges an EU state to notify at the time of conviction, is not retrospective. Accordingly, there are likely to be a pool of older prisoners who are UK nationals, serving sentences in EU prisons, which the Central Authority is not yet aware of. Further consideration could be given to making a request of each country in order to identify who these individuals are and the offences for which they have been convicted;
(ii) Consideration could be given to some form of “warning marker” which could be placed on an individual’s passport which would alert the authorities to the entry of a UK national convicted of murder, back into the UK. Furthermore, it might be possible for the Immigration Rules to be amended to enable a passport officer to request details from that individual as to the address they are going to stay at in UK; details of any car to be used by them; details of relatives; people they intend to stay with etc. The police are aware from the evidence disclosed in the Inquest (notably pre-sentence reports on ████████ that he was told by the German authorities upon his deportation that he would be met by Security Officers in the UK, who would ensure that he was given advice and keep an eye on him. It appears that this did not happen and he was free to enter the UK at Heathrow airport of 24th January, 2008 and met his father who was waiting for him;
(iii) Consideration needs to be given to putting in place a mechanism which notifies local police that someone with a conviction like the murder conviction ████████ has come to reside in their area .
(iv) There could be an amendment to allow for a Notification Orders to be applied for. The principle response of the Home Office/MoJ was to amend the law to allow for the police to apply for the Violent Offender Order (VOO) However, as you are aware such orders will only be granted if there is a risk that the individual is likely to commit one of more of the specified offences in Section 98(3) of the Criminal Justice and Immigration Act 2008. Those offences are 6 types of serious violent offences from Section 20 OAPA 1861 upwards to manslaughter.
It is doubtful that a VOO would have been granted in the case of ████████ following the incident in July 2008, as he had only been convicted of the offence of common assault and the circumstances of the sexual offence left on file would not be relevant.
(v) It may be possible for an amendment to be made to Schedule 3 of the Sexual Offences Act 2003 to include a foreign conviction for murder. With the benefit of hindsight this would allow the police to have applied for a Notification Order against ████████ as soon as they were aware of his existence. This would require him to comply with the notification requirements under section 83(5) of that Act requiring him to state his date of birth; national insurance number; home address and specify any address at which he stays on a periodic basis. It would be a useful mechanism to monitor an individual’s movements when no licence conditions would apply.
” 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 Government Legal Department; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure police awareness and protective conditions when individuals with foreign murder convictions enter the UK
Wider context from the report “Notwithstanding the changes that have occurred (i) enabling a Violent Offender Order to be made in relation to someone who has a conviction for murder (including murder abroad) in May 2014 and (ii) the EU Directive which requires EU member states to notify the UK of foreign convictions of UK Nationals, at the time of conviction (as opposed to later than this which occurred in the ████████ case) and (iii) the electronic system now in place at the Central Authority – it seems that there are further opportunities that might be considered which would reduce the likelihood of another individual (with a murder conviction like ████████) entering the UK without conditions and without any police force being made aware of that person’s existence , until arrested for different offence.
I ask the Home Office/MoJ to give consideration to further steps that could be taken to address the issues, including those detailed below. In making the suggestion below it is recognised that the issues are complex.
(i) The Central Authority needs to be notified now of all EU nationals currently serving a sentence for serious crimes such as murder in those countries. We understand the new notification system which obliges an EU state to notify at the time of conviction, is not retrospective. Accordingly, there are likely to be a pool of older prisoners who are UK nationals, serving sentences in EU prisons, which the Central Authority is not yet aware of. Further consideration could be given to making a request of each country in order to identify who these individuals are and the offences for which they have been convicted;
(ii) Consideration could be given to some form of “warning marker” which could be placed on an individual’s passport which would alert the authorities to the entry of a UK national convicted of murder, back into the UK. Furthermore, it might be possible for the Immigration Rules to be amended to enable a passport officer to request details from that individual as to the address they are going to stay at in UK; details of any car to be used by them; details of relatives; people they intend to stay with etc. The police are aware from the evidence disclosed in the Inquest (notably pre-sentence reports on ████████ that he was told by the German authorities upon his deportation that he would be met by Security Officers in the UK, who would ensure that he was given advice and keep an eye on him. It appears that this did not happen and he was free to enter the UK at Heathrow airport of 24th January, 2008 and met his father who was waiting for him;
(iii) Consideration needs to be given to putting in place a mechanism which notifies local police that someone with a conviction like the murder conviction ████████ has come to reside in their area.
(iv) There could be an amendment to allow for a Notification Orders to be applied for. The principle response of the Home Office/MoJ was to amend the law to allow for the police to apply for the Violent Offender Order (VOO) However, as you are aware such orders will only be granted if there is a risk that the individual is likely to commit one of more of the specified offences in Section 98(3) of the Criminal Justice and Immigration Act 2008. Those offences are 6 types of serious violent offences from Section 20 OAPA 1861 upwards to manslaughter.
It is doubtful that a VOO would have been granted in the case of ████████ following the incident in July 2008, as he had only been convicted of the offence of common assault and the circumstances of the sexual offence left on file would not be relevant.
(v) It may be possible for an amendment to be made to Schedule 3 of the Sexual Offences Act 2003 to include a foreign conviction for murder. With the benefit of hindsight this would allow the police to have applied for a Notification Order against ████████ as soon as they were aware of his existence. This would require him to comply with the notification requirements under section 83(5) of that Act requiring him to state his date of birth; national insurance number; home address and specify any address at which he stays on a periodic basis. It would be a useful mechanism to monitor an individual’s movements when no licence conditions would apply.
” 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 Government Legal Department; that does not assign responsibility.
PFD Monitor interpretation Exclusion of foreign murder convictions from the Notification Order framework
Wider context from the report “Notwithstanding the changes that have occurred (i) enabling a Violent Offender Order to be made in relation to someone who has a conviction for murder (including murder abroad) in May 2014 and (ii) the EU Directive which requires EU member states to notify the UK of foreign convictions of UK Nationals, at the time of conviction (as opposed to later than this which occurred in the ████████ case) and (iii) the electronic system now in place at the Central Authority – it seems that there are further opportunities that might be considered which would reduce the likelihood of another individual (with a murder conviction like ████████) entering the UK without conditions and without any police force being made aware of that person’s existence, until arrested for different offence.
I ask the Home Office/MoJ to give consideration to further steps that could be taken to address the issues, including those detailed below. In making the suggestion below it is recognised that the issues are complex.
(i) The Central Authority needs to be notified now of all EU nationals currently serving a sentence for serious crimes such as murder in those countries. We understand the new notification system which obliges an EU state to notify at the time of conviction, is not retrospective. Accordingly, there are likely to be a pool of older prisoners who are UK nationals, serving sentences in EU prisons, which the Central Authority is not yet aware of. Further consideration could be given to making a request of each country in order to identify who these individuals are and the offences for which they have been convicted;
(ii) Consideration could be given to some form of “warning marker” which could be placed on an individual’s passport which would alert the authorities to the entry of a UK national convicted of murder, back into the UK. Furthermore, it might be possible for the Immigration Rules to be amended to enable a passport officer to request details from that individual as to the address they are going to stay at in UK; details of any car to be used by them; details of relatives; people they intend to stay with etc. The police are aware from the evidence disclosed in the Inquest (notably pre-sentence reports on ████████ that he was told by the German authorities upon his deportation that he would be met by Security Officers in the UK, who would ensure that he was given advice and keep an eye on him. It appears that this did not happen and he was free to enter the UK at Heathrow airport of 24th January, 2008 and met his father who was waiting for him;
(iii) Consideration needs to be given to putting in place a mechanism which notifies local police that someone with a conviction like the murder conviction ████████ has come to reside in their area.
(iv) There could be an amendment to allow for a Notification Orders to be applied for. The principle response of the Home Office/MoJ was to amend the law to allow for the police to apply for the Violent Offender Order (VOO) However, as you are aware such orders will only be granted if there is a risk that the individual is likely to commit one of more of the specified offences in Section 98(3) of the Criminal Justice and Immigration Act 2008. Those offences are 6 types of serious violent offences from Section 20 OAPA 1861 upwards to manslaughter.
It is doubtful that a VOO would have been granted in the case of ████████ following the incident in July 2008, as he had only been convicted of the offence of common assault and the circumstances of the sexual offence left on file would not be relevant.
(v) It may be possible for an amendment to be made to Schedule 3 of the Sexual Offences Act 2003 to include a foreign conviction for murder . With the benefit of hindsight this would allow the police to have applied for a Notification Order against ████████ as soon as they were aware of his existence. This would require him to comply with the notification requirements under section 83(5) of that Act requiring him to state his date of birth; national insurance number; home address and specify any address at which he stays on a periodic basis. It would be a useful mechanism to monitor an individual’s movements when no licence conditions would apply .
” 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 Government Legal Department; that does not assign responsibility.
PFD Monitor interpretation Ineligibility of individuals with foreign murder convictions for a Violent Offender Order where the specified-offence risk threshold is not met
Wider context from the report “Notwithstanding the changes that have occurred (i) enabling a Violent Offender Order to be made in relation to someone who has a conviction for murder (including murder abroad) in May 2014 and (ii) the EU Directive which requires EU member states to notify the UK of foreign convictions of UK Nationals, at the time of conviction (as opposed to later than this which occurred in the ████████ case) and (iii) the electronic system now in place at the Central Authority – it seems that there are further opportunities that might be considered which would reduce the likelihood of another individual (with a murder conviction like ████████) entering the UK without conditions and without any police force being made aware of that person’s existence, until arrested for different offence.
I ask the Home Office/MoJ to give consideration to further steps that could be taken to address the issues, including those detailed below. In making the suggestion below it is recognised that the issues are complex.
(i) The Central Authority needs to be notified now of all EU nationals currently serving a sentence for serious crimes such as murder in those countries. We understand the new notification system which obliges an EU state to notify at the time of conviction, is not retrospective. Accordingly, there are likely to be a pool of older prisoners who are UK nationals, serving sentences in EU prisons, which the Central Authority is not yet aware of. Further consideration could be given to making a request of each country in order to identify who these individuals are and the offences for which they have been convicted;
(ii) Consideration could be given to some form of “warning marker” which could be placed on an individual’s passport which would alert the authorities to the entry of a UK national convicted of murder, back into the UK. Furthermore, it might be possible for the Immigration Rules to be amended to enable a passport officer to request details from that individual as to the address they are going to stay at in UK; details of any car to be used by them; details of relatives; people they intend to stay with etc. The police are aware from the evidence disclosed in the Inquest (notably pre-sentence reports on ████████ that he was told by the German authorities upon his deportation that he would be met by Security Officers in the UK, who would ensure that he was given advice and keep an eye on him. It appears that this did not happen and he was free to enter the UK at Heathrow airport of 24th January, 2008 and met his father who was waiting for him;
(iii) Consideration needs to be given to putting in place a mechanism which notifies local police that someone with a conviction like the murder conviction ████████ has come to reside in their area.
(iv) There could be an amendment to allow for a Notification Orders to be applied for. The principle response of the Home Office/MoJ was to amend the law to allow for the police to apply for the Violent Offender Order (VOO) However, as you are aware such orders will only be granted if there is a risk that the individual is likely to commit one of more of the specified offences in Section 98(3) of the Criminal Justice and Immigration Act 2008. Those offences are 6 types of serious violent offences from Section 20 OAPA 1861 upwards to manslaughter.
It is doubtful that a VOO would have been granted in the case of ████████ following the incident in July 2008, as he had only been convicted of the offence of common assault and the circumstances of the sexual offence left on file would not be relevant.
(v) It may be possible for an amendment to be made to Schedule 3 of the Sexual Offences Act 2003 to include a foreign conviction for murder. With the benefit of hindsight this would allow the police to have applied for a Notification Order against ████████ as soon as they were aware of his existence. This would require him to comply with the notification requirements under section 83(5) of that Act requiring him to state his date of birth; national insurance number; home address and specify any address at which he stays on a periodic basis. It would be a useful mechanism to monitor an individual’s movements when no licence conditions would apply.
” 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 Government Legal Department; that does not assign responsibility.
PFD Monitor interpretation Failure of the Central Authority to identify UK nationals serving sentences for serious crimes in EU prisons under the non-retrospective notification system
Wider context from the report “Notwithstanding the changes that have occurred (i) enabling a Violent Offender Order to be made in relation to someone who has a conviction for murder (including murder abroad) in May 2014 and (ii) the EU Directive which requires EU member states to notify the UK of foreign convictions of UK Nationals, at the time of conviction (as opposed to later than this which occurred in the ████████ case) and (iii) the electronic system now in place at the Central Authority – it seems that there are further opportunities that might be considered which would reduce the likelihood of another individual (with a murder conviction like ████████) entering the UK without conditions and without any police force being made aware of that person’s existence, until arrested for different offence.
I ask the Home Office/MoJ to give consideration to further steps that could be taken to address the issues, including those detailed below. In making the suggestion below it is recognised that the issues are complex.
(i) The Central Authority needs to be notified now of all EU nationals currently serving a sentence for serious crimes such as murder in those countries. We understand the new notification system which obliges an EU state to notify at the time of conviction, is not retrospective. Accordingly, there are likely to be a pool of older prisoners who are UK nationals, serving sentences in EU prisons, which the Central Authority is not yet aware of . Further consideration could be given to making a request of each country in order to identify who these individuals are and the offences for which they have been convicted;
(ii) Consideration could be given to some form of “warning marker” which could be placed on an individual’s passport which would alert the authorities to the entry of a UK national convicted of murder, back into the UK. Furthermore, it might be possible for the Immigration Rules to be amended to enable a passport officer to request details from that individual as to the address they are going to stay at in UK; details of any car to be used by them; details of relatives; people they intend to stay with etc. The police are aware from the evidence disclosed in the Inquest (notably pre-sentence reports on ████████ that he was told by the German authorities upon his deportation that he would be met by Security Officers in the UK, who would ensure that he was given advice and keep an eye on him. It appears that this did not happen and he was free to enter the UK at Heathrow airport of 24th January, 2008 and met his father who was waiting for him;
(iii) Consideration needs to be given to putting in place a mechanism which notifies local police that someone with a conviction like the murder conviction ████████ has come to reside in their area.
(iv) There could be an amendment to allow for a Notification Orders to be applied for. The principle response of the Home Office/MoJ was to amend the law to allow for the police to apply for the Violent Offender Order (VOO) However, as you are aware such orders will only be granted if there is a risk that the individual is likely to commit one of more of the specified offences in Section 98(3) of the Criminal Justice and Immigration Act 2008. Those offences are 6 types of serious violent offences from Section 20 OAPA 1861 upwards to manslaughter.
It is doubtful that a VOO would have been granted in the case of ████████ following the incident in July 2008, as he had only been convicted of the offence of common assault and the circumstances of the sexual offence left on file would not be relevant.
(v) It may be possible for an amendment to be made to Schedule 3 of the Sexual Offences Act 2003 to include a foreign conviction for murder. With the benefit of hindsight this would allow the police to have applied for a Notification Order against ████████ as soon as they were aware of his existence. This would require him to comply with the notification requirements under section 83(5) of that Act requiring him to state his date of birth; national insurance number; home address and specify any address at which he stays on a periodic basis. It would be a useful mechanism to monitor an individual’s movements when no licence conditions would apply.
” Open source report
Concerns raised 12 Failure to secure mutual aid for bed watch cover View source Lack of clarity about responsibility for funding and payment of privately funded care and transfers View source Lack of clarity about the circumstances and means for arranging hospital transfers View source Unavailability of scales in all medical consulting rooms View source Lack of a system guiding privately funded transfers between hospitals View source Failure of medical records to clearly record information availability, entry timing and authorship View source Failure of doctors and nurses to routinely weigh patients View source Lack of designated ownership and control for complex hospital transfer arrangements View source Lack of policy or guidance for prison staff and health care providers managing complex privately funded transfers View source Delays and limitations in liaison and communication between prison and hospital health care staff View source Lack of clarity in rules governing prisoners’ entitlement to private health care View source Lack of a formal policy for situations involving privately funded prisoner health care and hospital transfers 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
Zeeyad Hamadi · 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
Zeeyad Hamadi was a prisoner at HMP Frankland who became unwell, was diagnosed with Hodgkins Lymphoma, and deteriorated while arrangements were made to transfer him to a London hospital for private chemotherapy. Concerns included inadequate weighing and medical record keeping, limited communication between prison and hospital staff, unclear funding and transfer arrangements, and the absence of a system or responsible point of contact to manage the transfer, contributing to delay.
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 Government Legal Department; that does not assign responsibility.
PFD Monitor interpretation Failure to secure mutual aid for bed watch cover
Wider context from the report “(4) Requests by HMP Frankland for mutual aid from prisons in London to provide bed watch office cover were unsuccessful and it was only after the intervention of the governing Governor of HMP Frankland with a senior manager at the high security estate Headquarters of the prison service that an instruction was given for a London prison to provide bed watch cover. There was a lack of understanding as to and what circumstances the transfer from Durham to London could be facilitated by an NHS ambulance, a private ambulance or an air ambulance. There was no evidence to show bad faith on the part of any of the individuals who were involved in this transfer process but there was no system in place to aid those involved in this process to guide them as to how a transfer should properly be made from an NHS hospital in one part of the country to a hospital in another part of the country where treatment was to be privately funded. There was as a result no single point of contact within the prison (either of a health care or a discipline background) who was able to take ownership of the issue, or a group of people properly designated to take control of such a situation, with the result that in conjunction with the failure for mutual aid to be given the bed watch requirements for a delay to have taken place which could have reduced the deceased’s chances of receiving treatment which may have prolonged his life. Evidence was given that notwithstanding the fact that the deceased died in October 2010 no policy or guidance has been introduced to assist either prison service staff or health care providers with the issues highlighted by this case which were described in evidence as unprecedented.
Although there may be limited occasions when prisoners might have family resources to provide private medical care it is possible that more people will have the benefit of private medical insurance which may be of assistance in similar cases. The use of such private medical care covered by insurance would lead to a reduction in the cost burden imposed on the NHS.
” 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 Government Legal Department; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about responsibility for funding and payment of privately funded care and transfers
Wider context from the report “(3) There was limited liaison between health care staff in HMP Frankland and medical staff at UHND to monitor the deceased’s medical condition once he had left the prison. When a decision was made by the deceased to seek treatment in London on a private paying basis this information was not speedily communicated to those responsible for health care in HMP Frankland and contact was made by a hospital doctor with a duty governor at the prison who in turn had to refer to the health care manager. Confusion developed as to the basis of the proposed move to Bart’s from UHND; whether this was a prison to prison transfer or whether it was a relocation of the deceased from one hospital to another whilst remaining the responsibility of HMP Frankland. There was confusion over the funding arrangements for this proposal; whether the local NHS would be responsible for the medical treatment or the costs of transport, the form of such transport and/or the costs of bed watch. The brother of the deceased confirmed to different people at different times that he would undertake to be responsible for the costs incurred (subject to a challenge by Judicial review) and it took some time for the issues of funding to be identified before being addressed and resolved. There was a lack of clarity of understanding who would be responsible for what and when, so far as money was concerned and who would have the responsibility for payment in the first place prior to reimbursement by the deceased’s brother . There was no formal policy in place to deal with the situation. There was lack of clarity in the rules that were referred to in evidence as to how and when a convicted prisoner is entitled to private health care as opposed to a prisoner on 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 Government Legal Department; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about the circumstances and means for arranging hospital transfers
Wider context from the report “(4) Requests by HMP Frankland for mutual aid from prisons in London to provide bed watch office cover were unsuccessful and it was only after the intervention of the governing Governor of HMP Frankland with a senior manager at the high security estate Headquarters of the prison service that an instruction was given for a London prison to provide bed watch cover. There was a lack of understanding as to and what circumstances the transfer from Durham to London could be facilitated by an NHS ambulance, a private ambulance or an air ambulance . There was no evidence to show bad faith on the part of any of the individuals who were involved in this transfer process but there was no system in place to aid those involved in this process to guide them as to how a transfer should properly be made from an NHS hospital in one part of the country to a hospital in another part of the country where treatment was to be privately funded. There was as a result no single point of contact within the prison (either of a health care or a discipline background) who was able to take ownership of the issue, or a group of people properly designated to take control of such a situation, with the result that in conjunction with the failure for mutual aid to be given the bed watch requirements for a delay to have taken place which could have reduced the deceased’s chances of receiving treatment which may have prolonged his life. Evidence was given that notwithstanding the fact that the deceased died in October 2010 no policy or guidance has been introduced to assist either prison service staff or health care providers with the issues highlighted by this case which were described in evidence as unprecedented.
Although there may be limited occasions when prisoners might have family resources to provide private medical care it is possible that more people will have the benefit of private medical insurance which may be of assistance in similar cases. The use of such private medical care covered by insurance would lead to a reduction in the cost burden imposed on the NHS.
” 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 Government Legal Department; that does not assign responsibility.
PFD Monitor interpretation Unavailability of scales in all medical consulting rooms
Wider context from the report “(1) The evidence disclosed that the deceased had not been weighed at the times of medical appointments and a history of weight loss would have been a useful diagnostic tool. Not all medical consulting rooms at HMP Frankland had scales to do so and doctors/nurses did not routinely weigh patients.
” 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 Government Legal Department; that does not assign responsibility.
PFD Monitor interpretation Lack of a system guiding privately funded transfers between hospitals
Wider context from the report “(4) Requests by HMP Frankland for mutual aid from prisons in London to provide bed watch office cover were unsuccessful and it was only after the intervention of the governing Governor of HMP Frankland with a senior manager at the high security estate Headquarters of the prison service that an instruction was given for a London prison to provide bed watch cover. There was a lack of understanding as to and what circumstances the transfer from Durham to London could be facilitated by an NHS ambulance, a private ambulance or an air ambulance. There was no evidence to show bad faith on the part of any of the individuals who were involved in this transfer process but there was no system in place to aid those involved in this process to guide them as to how a transfer should properly be made from an NHS hospital in one part of the country to a hospital in another part of the country where treatment was to be privately funded . There was as a result no single point of contact within the prison (either of a health care or a discipline background) who was able to take ownership of the issue, or a group of people properly designated to take control of such a situation, with the result that in conjunction with the failure for mutual aid to be given the bed watch requirements for a delay to have taken place which could have reduced the deceased’s chances of receiving treatment which may have prolonged his life. Evidence was given that notwithstanding the fact that the deceased died in October 2010 no policy or guidance has been introduced to assist either prison service staff or health care providers with the issues highlighted by this case which were described in evidence as unprecedented.
Although there may be limited occasions when prisoners might have family resources to provide private medical care it is possible that more people will have the benefit of private medical insurance which may be of assistance in similar cases. The use of such private medical care covered by insurance would lead to a reduction in the cost burden imposed on the NHS.
” 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 Government Legal Department; that does not assign responsibility.
PFD Monitor interpretation Failure of medical records to clearly record information availability, entry timing and authorship
Wider context from the report “(2) It was accepted in evidence that the standard of record keeping in the patient’s medical notes was not as good as it could or should have been . There was lack of clarity as to when certain medical information (for example blood tests results) were available for interpretation by a doctor , by paper or electronic means, there was lack of clarity as from the computer printouts of medical records when entries were inputted into the system and were available for view, who was the author of the entry (as opposed to who inputted the data) .
” 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 Government Legal Department; that does not assign responsibility.
PFD Monitor interpretation Failure of doctors and nurses to routinely weigh patients
Wider context from the report “(1) The evidence disclosed that the deceased had not been weighed at the times of medical appointments and a history of weight loss would have been a useful diagnostic tool. Not all medical consulting rooms at HMP Frankland had scales to do so and doctors/nurses did not routinely weigh patients .
” 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 Government Legal Department; that does not assign responsibility.
PFD Monitor interpretation Lack of designated ownership and control for complex hospital transfer arrangements
Wider context from the report “(4) Requests by HMP Frankland for mutual aid from prisons in London to provide bed watch office cover were unsuccessful and it was only after the intervention of the governing Governor of HMP Frankland with a senior manager at the high security estate Headquarters of the prison service that an instruction was given for a London prison to provide bed watch cover. There was a lack of understanding as to and what circumstances the transfer from Durham to London could be facilitated by an NHS ambulance, a private ambulance or an air ambulance. There was no evidence to show bad faith on the part of any of the individuals who were involved in this transfer process but there was no system in place to aid those involved in this process to guide them as to how a transfer should properly be made from an NHS hospital in one part of the country to a hospital in another part of the country where treatment was to be privately funded. There was as a result no single point of contact within the prison (either of a health care or a discipline background) who was able to take ownership of the issue, or a group of people properly designated to take control of such a situation, with the result that in conjunction with the failure for mutual aid to be given the bed watch requirements for a delay to have taken place which could have reduced the deceased’s chances of receiving treatment which may have prolonged his life. Evidence was given that notwithstanding the fact that the deceased died in October 2010 no policy or guidance has been introduced to assist either prison service staff or health care providers with the issues highlighted by this case which were described in evidence as unprecedented.
Although there may be limited occasions when prisoners might have family resources to provide private medical care it is possible that more people will have the benefit of private medical insurance which may be of assistance in similar cases. The use of such private medical care covered by insurance would lead to a reduction in the cost burden imposed on the NHS.
” 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 Government Legal Department; that does not assign responsibility.
PFD Monitor interpretation Lack of policy or guidance for prison staff and health care providers managing complex privately funded transfers
Wider context from the report “(4) Requests by HMP Frankland for mutual aid from prisons in London to provide bed watch office cover were unsuccessful and it was only after the intervention of the governing Governor of HMP Frankland with a senior manager at the high security estate Headquarters of the prison service that an instruction was given for a London prison to provide bed watch cover. There was a lack of understanding as to and what circumstances the transfer from Durham to London could be facilitated by an NHS ambulance, a private ambulance or an air ambulance. There was no evidence to show bad faith on the part of any of the individuals who were involved in this transfer process but there was no system in place to aid those involved in this process to guide them as to how a transfer should properly be made from an NHS hospital in one part of the country to a hospital in another part of the country where treatment was to be privately funded. There was as a result no single point of contact within the prison (either of a health care or a discipline background) who was able to take ownership of the issue, or a group of people properly designated to take control of such a situation, with the result that in conjunction with the failure for mutual aid to be given the bed watch requirements for a delay to have taken place which could have reduced the deceased’s chances of receiving treatment which may have prolonged his life. Evidence was given that notwithstanding the fact that the deceased died in October 2010 no policy or guidance has been introduced to assist either prison service staff or health care providers with the issues highlighted by this case which were described in evidence as unprecedented.
Although there may be limited occasions when prisoners might have family resources to provide private medical care it is possible that more people will have the benefit of private medical insurance which may be of assistance in similar cases. The use of such private medical care covered by insurance would lead to a reduction in the cost burden imposed on the NHS.
” 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 Government Legal Department; that does not assign responsibility.
PFD Monitor interpretation Delays and limitations in liaison and communication between prison and hospital health care staff
Wider context from the report “(3) There was limited liaison between health care staff in HMP Frankland and medical staff at UHND to monitor the deceased’s medical condition once he had left the prison . When a decision was made by the deceased to seek treatment in London on a private paying basis this information was not speedily communicated to those responsible for health care in HMP Frankland and contact was made by a hospital doctor with a duty governor at the prison who in turn had to refer to the health care manager. Confusion developed as to the basis of the proposed move to Bart’s from UHND; whether this was a prison to prison transfer or whether it was a relocation of the deceased from one hospital to another whilst remaining the responsibility of HMP Frankland. There was confusion over the funding arrangements for this proposal; whether the local NHS would be responsible for the medical treatment or the costs of transport, the form of such transport and/or the costs of bed watch. The brother of the deceased confirmed to different people at different times that he would undertake to be responsible for the costs incurred (subject to a challenge by Judicial review) and it took some time for the issues of funding to be identified before being addressed and resolved. There was a lack of clarity of understanding who would be responsible for what and when, so far as money was concerned and who would have the responsibility for payment in the first place prior to reimbursement by the deceased’s brother. There was no formal policy in place to deal with the situation. There was lack of clarity in the rules that were referred to in evidence as to how and when a convicted prisoner is entitled to private health care as opposed to a prisoner on 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 Government Legal Department; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity in rules governing prisoners’ entitlement to private health care
Wider context from the report “(3) There was limited liaison between health care staff in HMP Frankland and medical staff at UHND to monitor the deceased’s medical condition once he had left the prison. When a decision was made by the deceased to seek treatment in London on a private paying basis this information was not speedily communicated to those responsible for health care in HMP Frankland and contact was made by a hospital doctor with a duty governor at the prison who in turn had to refer to the health care manager. Confusion developed as to the basis of the proposed move to Bart’s from UHND; whether this was a prison to prison transfer or whether it was a relocation of the deceased from one hospital to another whilst remaining the responsibility of HMP Frankland. There was confusion over the funding arrangements for this proposal; whether the local NHS would be responsible for the medical treatment or the costs of transport, the form of such transport and/or the costs of bed watch. The brother of the deceased confirmed to different people at different times that he would undertake to be responsible for the costs incurred (subject to a challenge by Judicial review) and it took some time for the issues of funding to be identified before being addressed and resolved. There was a lack of clarity of understanding who would be responsible for what and when, so far as money was concerned and who would have the responsibility for payment in the first place prior to reimbursement by the deceased’s brother. There was no formal policy in place to deal with the situation. There was lack of clarity in the rules that were referred to in evidence as to how and when a convicted prisoner is entitled to private health care as opposed to a prisoner on 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 Government Legal Department; that does not assign responsibility.
PFD Monitor interpretation Lack of a formal policy for situations involving privately funded prisoner health care and hospital transfers
Wider context from the report “(3) There was limited liaison between health care staff in HMP Frankland and medical staff at UHND to monitor the deceased’s medical condition once he had left the prison. When a decision was made by the deceased to seek treatment in London on a private paying basis this information was not speedily communicated to those responsible for health care in HMP Frankland and contact was made by a hospital doctor with a duty governor at the prison who in turn had to refer to the health care manager. Confusion developed as to the basis of the proposed move to Bart’s from UHND; whether this was a prison to prison transfer or whether it was a relocation of the deceased from one hospital to another whilst remaining the responsibility of HMP Frankland. There was confusion over the funding arrangements for this proposal; whether the local NHS would be responsible for the medical treatment or the costs of transport, the form of such transport and/or the costs of bed watch. The brother of the deceased confirmed to different people at different times that he would undertake to be responsible for the costs incurred (subject to a challenge by Judicial review) and it took some time for the issues of funding to be identified before being addressed and resolved. There was a lack of clarity of understanding who would be responsible for what and when, so far as money was concerned and who would have the responsibility for payment in the first place prior to reimbursement by the deceased’s brother. There was no formal policy in place to deal with the situation . There was lack of clarity in the rules that were referred to in evidence as to how and when a convicted prisoner is entitled to private health care as opposed to a prisoner on remand.
” Open source report
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Request correction
Addressed to Treasury Solicitor’s Department, now represented here by Government Legal Department.
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations