25 Jul 2025 Sheldon Lawrence Jeans · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 4 Lack of policy and guidance informing prison staff of the dangers of illicitly brewed alcohol View source Failure to secure in-possession medication against access by other prisoners View source Lack of policy and guidance governing access to and use of illicitly brewed alcohol in prisons View source Failure to ensure return of excess medication after prescription discontinuation 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.
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AI-generated summary
Sheldon Lawrence Jeans · 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
On 13 November 2022, Sheldon Lawrence Jeans, a serving prisoner at HMP Guys Marsh, was found collapsed and unresponsive in his cell. The inquest recorded that he died following an idiosyncratic response to alcoholic intoxication and medicinal drugs, combined with partial postural asphyxia. The report raised concerns about the lack of guidance on illicitly brewed alcohol and the governance, storage and return of medication held by prisoners.
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 Guys Marsh Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of policy and guidance informing prison staff of the dangers of illicitly brewed alcohol
Wider context from the report “(1) There is a lack of national policy, and local guidance at HMP Guys Marsh, to inform staff working in prisons of the dangers of illicitly brewed alcohol, also known as hooch. There is also a lack of policy and guidance to assist those working within the prisoner estate with the management and governance of the access to, and use of, illicitly brewed alcohol.
Illicitly brewed alcohol is a common substance across the prisoner estate. Evidence was given at the Inquest that in the month of September 2022, 215.5 litres of illicitly brewed alcohol were seized at HMP Guys Marsh. Evidence was given that Hooch continues to be a common problem in prisons. Illicitly brewed alcohol in prison is a substance made from items which are readily and legitimately available to prisoners.
Hooch was described as a very, very dangerous substance during the course of the evidence and as is clear from the cause of his death, was central to the death of Sheldon. Evidence was given that it has sedative effects which if taken with certain medications can increase the sedative effects.
Evidence was given that the policies in place concerning the possession and use of illicit substances within the prisoner estate at the time of Sheldon’s death, and those in place now, focus on drugs or medication, but are silent in relation to alcohol. I am concerned that this lack of guidance could lead to a future death in prison custody
” 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 Guys Marsh Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to secure in-possession medication against access by other prisoners
Wider context from the report “(2) Prisoners can have access to certain medication to hold in their possession which could be accessed by other prisoners and there is a lack of national policy, and local policy at HMP Guys Marsh, from a healthcare and prison perspective, around the governance of medication held in possession in the prisoner estate.
Evidence was heard that when a person is prescribed medication in prison, it can either be taken under supervision, or a prisoner can be provided with the medication to hold in their possession, in their cell.
In these cases, the prisoner is responsible for the safety of that medication. Prior to being provided with medication in their possession a risk assessment is undertaken upon the prisoner to assess the risks associated with the drug and also the risks associated with prisoner. Whilst medications defined as controlled drugs would not be given in possession, it is possible to have medication that could cause death in possession. Although Sheldon was not prescribed the medications that caused his death, evidence was given some of those medications are suitable to be prescribed to a prisoner in possession. It is not know how Sheldon accessed the medication found in his system at the time of his death, other than to say he obtained it at HMP Guys Marsh.
At HMP Guys Marsh, which may not be the case across the prisoner estate, a lockable cupboard is provided in cells for the storage of medication.
Evidence was given that at times cells will be left insecure at HMP Guys Marsh when the prison is in a state of unlock, such as when prisoners collect meals or for example when they go for showers or are out of the cells on association. Evidence was given that prisoners go into each other's cells when they are in a state of unlock. Prisoners could therefore enter another prisoner's cell. If medication is not held securely in a lockable cupboard there is a risk that prisoners who are not prescribed medication, could access medication.
Evidence was given at the Inquest that due to the chaotic life some prisoners lead, even when provided with lockable cupboards, cells at HMP Guys Marsh have been seen to contain medication that is not secure and is strewn all over the cell. The medication in Sheldon’s cell at the time of his death was found insecure in a Tupperware container.
Further, if a medication prescribed to a prisoner is discontinued, evidence was heard that the onus is upon the prisoner returning any excess medication to the healthcare department at HMP Guys Marsh which may be the position in other prisons.
The issues around securing of medication held in possession in a cell and the onus being upon prisoners to return unused medication, carries a risk of prisoners accessing unprescribed medication. At the time of Sheldon’s death he was not prescribed the medications found in his system and he had in his cell excessive amounts of medication he was prescribed and had previously been prescribed and discontinued.
I am therefore concerned the lack of guidance and policy nationally, and locally at HMP Guys Marsh, on storage of in possession medication and what to do when a medication is discontinued to ensure prisoners do not continue to possess left over medication, could lead to future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Guys Marsh Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of policy and guidance governing access to and use of illicitly brewed alcohol in prisons
Wider context from the report “(1) There is a lack of national policy, and local guidance at HMP Guys Marsh, to inform staff working in prisons of the dangers of illicitly brewed alcohol, also known as hooch. There is also a lack of policy and guidance to assist those working within the prisoner estate with the management and governance of the access to, and use of, illicitly brewed alcohol.
Illicitly brewed alcohol is a common substance across the prisoner estate. Evidence was given at the Inquest that in the month of September 2022, 215.5 litres of illicitly brewed alcohol were seized at HMP Guys Marsh. Evidence was given that Hooch continues to be a common problem in prisons. Illicitly brewed alcohol in prison is a substance made from items which are readily and legitimately available to prisoners.
Hooch was described as a very, very dangerous substance during the course of the evidence and as is clear from the cause of his death, was central to the death of Sheldon. Evidence was given that it has sedative effects which if taken with certain medications can increase the sedative effects.
Evidence was given that the policies in place concerning the possession and use of illicit substances within the prisoner estate at the time of Sheldon’s death, and those in place now, focus on drugs or medication, but are silent in relation to alcohol. I am concerned that this lack of guidance could lead to a future death in prison custody
” 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 Guys Marsh Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure return of excess medication after prescription discontinuation
Wider context from the report “(2) Prisoners can have access to certain medication to hold in their possession which could be accessed by other prisoners and there is a lack of national policy, and local policy at HMP Guys Marsh, from a healthcare and prison perspective, around the governance of medication held in possession in the prisoner estate.
Evidence was heard that when a person is prescribed medication in prison, it can either be taken under supervision, or a prisoner can be provided with the medication to hold in their possession, in their cell.
In these cases, the prisoner is responsible for the safety of that medication. Prior to being provided with medication in their possession a risk assessment is undertaken upon the prisoner to assess the risks associated with the drug and also the risks associated with prisoner. Whilst medications defined as controlled drugs would not be given in possession, it is possible to have medication that could cause death in possession. Although Sheldon was not prescribed the medications that caused his death, evidence was given some of those medications are suitable to be prescribed to a prisoner in possession. It is not know how Sheldon accessed the medication found in his system at the time of his death, other than to say he obtained it at HMP Guys Marsh.
At HMP Guys Marsh, which may not be the case across the prisoner estate, a lockable cupboard is provided in cells for the storage of medication.
Evidence was given that at times cells will be left insecure at HMP Guys Marsh when the prison is in a state of unlock, such as when prisoners collect meals or for example when they go for showers or are out of the cells on association. Evidence was given that prisoners go into each other's cells when they are in a state of unlock. Prisoners could therefore enter another prisoner's cell. If medication is not held securely in a lockable cupboard there is a risk that prisoners who are not prescribed medication, could access medication.
Evidence was given at the Inquest that due to the chaotic life some prisoners lead, even when provided with lockable cupboards, cells at HMP Guys Marsh have been seen to contain medication that is not secure and is strewn all over the cell. The medication in Sheldon’s cell at the time of his death was found insecure in a Tupperware container.
Further, if a medication prescribed to a prisoner is discontinued, evidence was heard that the onus is upon the prisoner returning any excess medication to the healthcare department at HMP Guys Marsh which may be the position in other prisons.
The issues around securing of medication held in possession in a cell and the onus being upon prisoners to return unused medication, carries a risk of prisoners accessing unprescribed medication. At the time of Sheldon’s death he was not prescribed the medications found in his system and he had in his cell excessive amounts of medication he was prescribed and had previously been prescribed and discontinued.
I am therefore concerned the lack of guidance and policy nationally, and locally at HMP Guys Marsh, on storage of in possession medication and what to do when a medication is discontinued to ensure prisoners do not continue to possess left over medication , could lead to future deaths.
” Open source report
31 May 2024 Frazer Charlie Williams · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 17 Lack of guidance on transferring prisoners under healthcare-team care between establishments View source Lack of national guidance for management and operational staff on pre-transfer prisoner handover View source Lack of consultation with receiving-prison healthcare teams about care capability View source Lack of national guidance for healthcare handover to receiving prisons View source Failure to deliver the keyworker scheme in line with national guidance View source Lack of process for recording and involving prisoners’ next of kin View source Lack of NHS and joint HMPPS guidance on identifying, managing and treating self-neglect in prisons View source Delays in transferring prisoners requiring mental health hospital admission View source Lack of a national directory of healthcare facilities and provision at individual prisons View source Lack of guidance requiring consultation with prison doctors before transferring prisoners receiving medical care View source Lack of automatic flagging of missed ACCT reviews View source Lack of ACCT quality assurance between day 7 and post-closure review View source Failure to make an immediate ambulance call when a code blue or red is raised View source Failure to invite relevant individuals such as key workers to ACCT reviews View source Lack of national specification for prison healthcare units View source Failure of the email-a-prisoner system to facilitate contact after unrecognised prisoner transfers View source Camouflaging similarity between cell-door and bedsheet colours View source See 14 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Frazer Charlie Williams · 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
Frazer Charlie Williams was found deceased on 7 March 2022 in his cell at HMP Guys Marsh, suspended by a ligature. The report identifies concerns about delays transferring prisoners requiring mental health hospital care, inadequate arrangements for managing self-neglect and healthcare handovers, shortcomings in ACCT monitoring and reviews, and other prison care and safety processes. The inquest concluded that he died by suicide in circumstances where there was inadequate assessment and monitoring of his risks of self-harm and suicide prior to his death.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Guys Marsh Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on transferring prisoners under healthcare-team care between establishments
Wider context from the report “iii. There is a lack of a national directory detailing the facilities and provision of healthcare at individual prisons across England and Wales, and associated guidance on the transfer of individuals between prison establishments when they are under the care of the healthcare teams and are not placed on medical hold . There is a lack of guidance on consultation with prison doctors where a prisoner is receiving medical care, whether that be for physical or mental health, when there is consideration by the prison to transfer the prisoner who is not placed on medical hold. Further there is a lack of consultation with the healthcare team at the proposed receiving prison to ensure they can provide the appropriate care for the person.
” 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 Guys Marsh Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidance for management and operational staff on pre-transfer prisoner handover
Wider context from the report “vi. There is lack of national guidance for both senior management and operational prison staff in relation to the handover of a prisoner in advance of their transfer , not specific to, but especially those with complex needs, when transferring between prisons.
” 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 Guys Marsh Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of consultation with receiving-prison healthcare teams about care capability
Wider context from the report “iii. There is a lack of a national directory detailing the facilities and provision of healthcare at individual prisons across England and Wales, and associated guidance on the transfer of individuals between prison establishments when they are under the care of the healthcare teams and are not placed on medical hold. There is a lack of guidance on consultation with prison doctors where a prisoner is receiving medical care, whether that be for physical or mental health, when there is consideration by the prison to transfer the prisoner who is not placed on medical hold. Further there is a lack of consultation with the healthcare team at the proposed receiving prison to ensure they can provide the appropriate care for the person .
” 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 Guys Marsh Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidance for healthcare handover to receiving prisons
Wider context from the report “iv. There is a lack of national guidance for healthcare teams working in prisons around the handover of healthcare of a prisoner to the receiving prison when they are transferred to another prison.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Guys Marsh Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to deliver the keyworker scheme in line with national guidance
Wider context from the report “x. The keyworker scheme is not being delivered in line with national guidance at HMP Guys Marsh.
” 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 Guys Marsh Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of process for recording and involving prisoners’ next of kin
Wider context from the report “xiii. There is a lack of process regarding the recording of a prisoner’s next of kin and involvement of them at HMP Guys Marsh.
” 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 Guys Marsh Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of NHS and joint HMPPS guidance on identifying, managing and treating self-neglect in prisons
Wider context from the report “ii. There is a lack of NHS guidance, and joint guidance with HMPPS, on the identification, management, and treatment of someone with self neglect in the prison setting .
” 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 Guys Marsh Prison; that does not assign responsibility.
PFD Monitor interpretation Delays in transferring prisoners requiring mental health hospital admission
Wider context from the report “i. There is inequity within the system of the treatment of a person with mental illness in the prison setting compared to an individual in the community, due to the fact that in the community a person would be placed in a hospital setting on the day they were deemed to require hospital admission, however in prison there are delays in transferring a prisoner in the same situation to hospital .
” 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 Guys Marsh Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of a national directory of healthcare facilities and provision at individual prisons
Wider context from the report “iii. There is a lack of a national directory detailing the facilities and provision of healthcare at individual prisons across England and Wales , and associated guidance on the transfer of individuals between prison establishments when they are under the care of the healthcare teams and are not placed on medical hold. There is a lack of guidance on consultation with prison doctors where a prisoner is receiving medical care, whether that be for physical or mental health, when there is consideration by the prison to transfer the prisoner who is not placed on medical hold. Further there is a lack of consultation with the healthcare team at the proposed receiving prison to ensure they can provide the appropriate care for the person.
” 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 Guys Marsh Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance requiring consultation with prison doctors before transferring prisoners receiving medical care
Wider context from the report “iii. There is a lack of a national directory detailing the facilities and provision of healthcare at individual prisons across England and Wales, and associated guidance on the transfer of individuals between prison establishments when they are under the care of the healthcare teams and are not placed on medical hold. There is a lack of guidance on consultation with prison doctors where a prisoner is receiving medical care , whether that be for physical or mental health, when there is consideration by the prison to transfer the prisoner who is not placed on medical hold . Further there is a lack of consultation with the healthcare team at the proposed receiving prison to ensure they can provide the appropriate care for the person.
” 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 Guys Marsh Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of automatic flagging of missed ACCT reviews
Wider context from the report “viii. There is lack of automatic flagging of a missed ACCT review at HMP Guys Marsh and this could also be a national problem.
” 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 Guys Marsh Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of ACCT quality assurance between day 7 and post-closure review
Wider context from the report “vii. The lack of ACCT quality assurance, or audit, between day 7 of the ACCT and the post closure review .
” 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 Guys Marsh Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to make an immediate ambulance call when a code blue or red is raised
Wider context from the report “xii. PSI 03/2013 is not being followed at HMP Guys Marsh as there is no immediate call to the ambulance service when a code blue or red is raised .
” 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 Guys Marsh Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to invite relevant individuals such as key workers to ACCT reviews
Wider context from the report “ix. Relevant individuals, such as key workers are not being invited to attend ACCT reviews at HMP Guys Marsh in line with ACCT 6 guidance.
” 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 Guys Marsh Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of national specification for prison healthcare units
Wider context from the report “v. There is a lack of national specification in respect of prison healthcare units .
” 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 Guys Marsh Prison; that does not assign responsibility.
PFD Monitor interpretation Failure of the email-a-prisoner system to facilitate contact after unrecognised prisoner transfers
Wider context from the report “xiv. The email a prisoner system is dependant on the person wanting to contact the prisoner knowing their location , so if the prisoner is transferred to another prison and the person contacting them is not aware, contact which can be a protective factor particularly in a prisoner’s mental health care, will not be facilitated.
” 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 Guys Marsh Prison; that does not assign responsibility.
PFD Monitor interpretation Camouflaging similarity between cell-door and bedsheet colours
Wider context from the report “xi. The colour of the cell doors and bedsheets at HMP Guys Marsh, and possibly at other prisons nationally, being very similar can camouflage ligatures .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish a process for recording next-of-kin details and submitting them on NOMIS.
Verbatim wording from the response “The Safety Team have recently addressed the process for recording details. OMU now identify the NOK and submit the information on NOMIS. In Frazer’s case he stated he had no NOK.” Source location Response from HMPPS / HMP Guys Marsh
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Circulate and mandate Code Red/Blue NTS and follow PSI contingency responses.
Verbatim wording from the response “Code red/blue NTS was recently circulated and labelled mandatory. All contingency responses (Annex A of the PSI) is followed and was on the last 2 deaths.” Source location Response from HMPPS / HMP Guys Marsh
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Enable Band 3 officers to attend ACCT reviews from October 2024.
Verbatim wording from the response “We facilitate MDT reviews; however, due to current Staffing levels, Band 3 Officers are unable to attend ACCT reviews. This will be corrected from October 2024 onwards.” Source location Response from HMPPS / HMP Guys Marsh
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce the Band 3 group to support delivery of the keyworker scheme.
Verbatim wording from the response “The Band 3 group will be introduced in September 2024.” Source location Response from HMPPS / HMP Guys Marsh
Open published response
×
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 Explore and, where appropriate, resolve the cell-door and bedsheet colour camouflage issue.
Verbatim wording from the response “This has been escalated for exploration of the issue and, if appropriate, resolution/action, is ongoing.” Source location Response from HMPPS / HMP Guys Marsh
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct weekly ACCT completion checks and monthly regional ACCT summaries.
Verbatim wording from the response “The Custodial Manager within the Safety function is responsible for ensuring that ACCTs are completed and a weekly basis. The Regional team also attend GM monthly and undertake ACCT summary.” Source location Response from HMPPS / HMP Guys Marsh
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 Mandatory code red and blue procedures and PSI contingency arrangements are considered sufficient and are being followed.
Verbatim wording from the response “xii. PSI 03/2013 is not being followed at HMP Guys Marsh as there is no immediate call to the ambulance service when a code blue or red is raised.” Source location Response from HMPPS / HMP Guys Marsh
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 Current staffing levels prevent Band 3 officers from attending ACCT reviews until October 2024.
Verbatim wording from the response “ix. Relevant individuals, such as key workers are not being invited to attend ACCT reviews at HMP Guys Marsh in line with ACCT 6 guidance.” Source location Response from HMPPS / HMP Guys Marsh
Open published response
2 Feb 2023 Jason Anthony Williams · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 4 Failure to issue Governor notices in response to increased psychoactive substance risks View source Lack of specific and dedicated guidance for defining and caring for vulnerable prisoners View source Inadequate quantity and quality of prison staff record keeping on NOMIS View source Failure of the keyworker programme to operate as planned View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jason Anthony Williams · 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
Jason Anthony Williams was found unresponsive in his cell at HMP Guys Marsh on 31 July 2020, and his death was confirmed by paramedics. The report states that synthetic cannabinoid intoxication was the medical cause of death and that he had deliberately taken drugs without intending fatal consequences. Concerns included inadequate guidance on vulnerable prisoners, shortcomings in the keyworker programme and NOMIS record keeping, and the absence of a Governor notice about increased psychoactive-substance risks.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Guys Marsh Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to issue Governor notices in response to increased psychoactive substance risks
Wider context from the report “iv. A Governor notice was not issued in the time leading up to Jason’s death to prisoners or staff around the concerns regarding access to, and the impact of using, psychoactive substances . I request that consideration is given to a review being undertaken by HMP Guys Marsh as to when such notices should be issued, particularly in relation to increased risks to prisoners around drug use.
” 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 Guys Marsh Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of specific and dedicated guidance for defining and caring for vulnerable prisoners
Wider context from the report “i. There is a lack of specific and dedicated national guidance to prison and healthcare staff on how to define and care for vulnerable prisoners. I would request that consideration is given to producing national guidance on this, to also include guidance on addressing self-neglect .
” 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 Guys Marsh Prison; that does not assign responsibility.
PFD Monitor interpretation Inadequate quantity and quality of prison staff record keeping on NOMIS
Wider context from the report “iii. The quantity and quality of record keeping by prison staff at HMP Guys Marsh on NOMIS . I request that consideration is given to providing refresher training to prison staff on record keeping to cover the importance of records and their contents, and the required regularity of recording.
” 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 Guys Marsh Prison; that does not assign responsibility.
PFD Monitor interpretation Failure of the keyworker programme to operate as planned
Wider context from the report “ii. The current keyworker programme is not working as planned at HMP Guys Marsh and there was reference to this also being reflected nationally . I would request that consideration is given to a review being undertaken of the keyworker programme within the whole prison estate, and also specifically at HMP Guys Marsh.
” 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 Introduce an assurance check for regular case-note entries.
Verbatim wording from the response “As you are aware on 11 April 2023, ████████, Director General Operations, on behalf of His Majesty’s Prison and Probation Service (HMPPS), wrote to you providing a response to the concerns you had raised in relation to the Prison Service. The response sets out the action that is being taken locally at HMP Guys Marsh, such as the introduction of a Buddy scheme, the writing of local guidance for those at risk of self-neglect and the introduction of an assurance check to ensure there are regular case note entries being made. It also provides information about the weekly multi-disciplinary meeting (Restrict Supply Tasking Group) that discusses and shares information regarding the drug ingress into the HMP Guys Marsh.” Source location Response from HM Prison & Probation Service 2
Open published response
×
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 Write local guidance for people at risk of self-neglect.
Verbatim wording from the response “As you are aware on 11 April 2023, ████████, Director General Operations, on behalf of His Majesty’s Prison and Probation Service (HMPPS), wrote to you providing a response to the concerns you had raised in relation to the Prison Service. The response sets out the action that is being taken locally at HMP Guys Marsh, such as the introduction of a Buddy scheme, the writing of local guidance for those at risk of self-neglect and the introduction of an assurance check to ensure there are regular case note entries being made. It also provides information about the weekly multi-disciplinary meeting (Restrict Supply Tasking Group) that discusses and shares information regarding the drug ingress into the HMP Guys Marsh.” Source location Response from HM Prison & Probation Service 2
Open published response
7 Apr 2022 Nicholas Tom Rose · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 1 Failure to require an appropriate verbal response during welfare checks 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
Nicholas Tom Rose · 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
Nicholas Tom Rose, a serving prisoner at HMP Guys Marsh, was found deceased in his cell on 19 May 2019 after consuming “Spice”, with the medical cause of death involving airway obstruction and aspiration of gastric content. The report raised concern that accepting a “grunt” as a verbal response during a welfare check may provide insufficient information to assess a prisoner's welfare and could contribute to future deaths if the practice continued.
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 Guys Marsh Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to require an appropriate verbal response during welfare checks
Wider context from the report “i. I am concerned that accepting a “grunt” as a verbal response to a welfare check does not fulfil the requirement as set out in the Notice to Prison Officers mentioned above. Such a response gives very limited information upon which a prison officer can assess a prisoner’s welfare . Accepting such a response potentially loses sight of the purpose of a welfare check, which must be to check that the prisoner is alive, immediately safe and well; that is, that they are conscious, breathing, not in a state of distress, not in a state of intoxication and that there are not any other factors that might require immediate intervention to prevent harm. A verbal response to a welfare check allows a prison officer to assess if a prisoner has responded in an appropriate manner, giving an indication as to whether the prisoner retains the cognitive function to provide an appropriate response. A “grunt” does not allow such an assessment . Therefore, I have a concern that future deaths could occur if accepting such a response remains the accepted practice .
” Open source report
22 Dec 2021 Kyle Nel · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 4 Failure to provide a formal written response to family or friends raising prisoner health or welfare concerns View source Failure of prison security fences to prevent the transfer of drugs and other prohibited materials between prisoners View source Failure to keep a computer record of family or friend concerns and measures taken to address them View source Failure to use a structured approach for responding to family or friend concerns about prisoner health or welfare 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.
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AI-generated summary
Kyle Nel · 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
Kyle Nel, a serving prisoner at HMP Guys Marsh, was found unconscious in his cell on 9 June 2018 and was subsequently declared dead after resuscitation attempts. The inquest recorded the medical cause of death as aspiration of gastric contents associated with synthetic cannabinoid (5F-ADB), also known as “Spice”, use, with a conclusion of misadventure. Concerns included the prison’s handling and recording of welfare concerns raised by families and the ability to pass drugs and other prohibited items between prison units through security fences.
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 Guys Marsh Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to provide a formal written response to family or friends raising prisoner health or welfare concerns
Wider context from the report “i) I have concerns that when members of a prisoner’s family or friends contact the prison raising concerns as to the health or welfare of a prisoner, there needs to be structured approach and computer record kept of those concerns, the measures taken to deal with the concerns and a formal written response to the family or friends who have raised those concerns . It is understood that while there are potential security and confidentiality issues that may arise from this process suitable measures should be considered and implemented.
” 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 Guys Marsh Prison; that does not assign responsibility.
PFD Monitor interpretation Failure of prison security fences to prevent the transfer of drugs and other prohibited materials between prisoners
Wider context from the report “ii) The security fences within the prison estate need to be reviewed and consideration urgently given to prevent drugs and other prohibited materials being passed between prisoners through the fences .
” 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 Guys Marsh Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to keep a computer record of family or friend concerns and measures taken to address them
Wider context from the report “i) I have concerns that when members of a prisoner’s family or friends contact the prison raising concerns as to the health or welfare of a prisoner, there needs to be structured approach and computer record kept of those concerns, the measures taken to deal with the concerns and a formal written response to the family or friends who have raised those concerns. It is understood that while there are potential security and confidentiality issues that may arise from this process suitable measures should be considered and implemented.
” 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 Guys Marsh Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to use a structured approach for responding to family or friend concerns about prisoner health or welfare
Wider context from the report “i) I have concerns that when members of a prisoner’s family or friends contact the prison raising concerns as to the health or welfare of a prisoner, there needs to be structured approach and computer record kept of those concerns, the measures taken to deal with the concerns and a formal written response to the family or friends who have raised those concerns. It is understood that while there are potential security and confidentiality issues that may arise from this process suitable measures should be considered and implemented.
” Open source report
25 Jun 2018 Andrew Craig · Prevention of Future Deaths report Dorset
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Concerns raised 3 Ongoing use of prescription and illicit drugs at HMP Guys Marsh View source Failure of medication-dispensing arrangements to prevent undetected transfer of prescription drugs View source Failure to monitor whether prisoners swallow dispensed medication 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
Andrew Craig · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Andrew Craig, a serving prisoner at HMP Guys Marsh, was found collapsed and unresponsive in his cell on 16 September 2016. The inquest concluded that the medical cause of death was the toxic effects of buprenorphine and diazepam, with a conclusion of misadventure. The principal concerns were illicit drug use at the prison and weaknesses in the dispensing and monitoring of medication, which could facilitate the redistribution of prescription drugs.
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 Guys Marsh Prison; that does not assign responsibility.
PFD Monitor interpretation Ongoing use of prescription and illicit drugs at HMP Guys Marsh
Wider context from the report “i. There is an ongoing problem with the use of drugs, both prescription and illicit drugs such as psychoactive substances, at HMP Guys Marsh and there have been a number of recent deaths either confirmed to be, or suspected to be, due to drug use.
” 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 Guys Marsh Prison; that does not assign responsibility.
PFD Monitor interpretation Failure of medication-dispensing arrangements to prevent undetected transfer of prescription drugs
Wider context from the report “ii. Evidence was given by the Head of Healthcare, ████████ that there are 3 allocated times during the day when Prisoners collect medication. During these times, there are around 70 prisoners collecting their medication. The room can be quite chaotic and loud, and prisoners can be in close contact clambering over each other. She described the hatch as overloaded. This is an ideal scenario to pass medication to one another without detection.
iii. In addition, during the routine medication dispensing, there are no checks done to confirm that Prisoners have actually swallowed the medication. This can allow them to retain the medication for redistribution.
iv. At the last inspection by Her Majesty’s Inspectorate of Prisons these issues were raised and attempts have been made to improve the situation. There are now Prison Officers at the Healthcare department during dispensing times, but usually only one Officer stood in the room where the medication hatch is located and another outside the room. Despite these changes, Mrs Jameson advised that the arrangements at medication dispensing times continue to be an ongoing problem that facilitates the illicit supply of prescription drugs in the Prison . She advised that the process could be made safer and more secure. Similar concerns were also raised by one of the Prison GPs ████████
████████
v. Mrs Jameson also gave evidence that the Prison is overwhelmed with illicit drug use, particularly psychoactive substances and that the Healthcare team receive 3 emergency calls a week at HMP Guys Marsh to assist in resuscitating Prisoners from drug overdoses.
2. I have concerns with regard to the following:
i. There is an ongoing problem with the use of drugs, both prescription and illicit drugs such as psychoactive substances, at HMP Guys Marsh and there have been a number of recent deaths either confirmed to be, or suspected to be, due to drug use.
ii. Although the Prison are working to address this, further consideration needs to be given to restricting the supply of such drugs. I would request that to prevent a future death at HMP Guys Marsh, there is a review of the policies and procedures by both the Prison Staff and the Healthcare Staff regarding the dispensing and monitoring of the medication administered at the medication hatch to ensure compliance and reduce distribution to others.
” 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 Guys Marsh Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to monitor whether prisoners swallow dispensed medication
Wider context from the report “ii. Evidence was given by the Head of Healthcare, ████████ that there are 3 allocated times during the day when Prisoners collect medication. During these times, there are around 70 prisoners collecting their medication. The room can be quite chaotic and loud, and prisoners can be in close contact clambering over each other. She described the hatch as overloaded. This is an ideal scenario to pass medication to one another without detection.
iii. In addition, during the routine medication dispensing, there are no checks done to confirm that Prisoners have actually swallowed the medication. This can allow them to retain the medication for redistribution.
iv. At the last inspection by Her Majesty’s Inspectorate of Prisons these issues were raised and attempts have been made to improve the situation. There are now Prison Officers at the Healthcare department during dispensing times, but usually only one Officer stood in the room where the medication hatch is located and another outside the room. Despite these changes, Mrs Jameson advised that the arrangements at medication dispensing times continue to be an ongoing problem that facilitates the illicit supply of prescription drugs in the Prison. She advised that the process could be made safer and more secure. Similar concerns were also raised by one of the Prison GPs ████████
████████
v. Mrs Jameson also gave evidence that the Prison is overwhelmed with illicit drug use, particularly psychoactive substances and that the Healthcare team receive 3 emergency calls a week at HMP Guys Marsh to assist in resuscitating Prisoners from drug overdoses.
2. I have concerns with regard to the following:
i. There is an ongoing problem with the use of drugs, both prescription and illicit drugs such as psychoactive substances, at HMP Guys Marsh and there have been a number of recent deaths either confirmed to be, or suspected to be, due to drug use.
ii. Although the Prison are working to address this, further consideration needs to be given to restricting the supply of such drugs. I would request that to prevent a future death at HMP Guys Marsh, there is a review of the policies and procedures by both the Prison Staff and the Healthcare Staff regarding the dispensing and monitoring of the medication administered at the medication hatch to ensure compliance and reduce distribution to others.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations