Recipient

HCRG Care Ltd

First report 27 Oct 2014•Latest report 25 Oct 2016

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Private limited company. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 4
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

0%published responses found

0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

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

25 Oct2016
Inner South London
Concerns raised6
1. Failure to consider the whole person and reconcile or communicate missing and discordant information during proforma completion
2. Failure of detained organisations to pass risk information consistently between one another
3. Inadequate nurse assessment of fitness for segregation
1. Lack of an agreed system for transferring health care information from police stations or courts to prisons
2. Inadequate standard of Mental Health Act assessments
3. Lack of clear responsibility for passing or seeking relevant information
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

Richard Walsh · 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

Richard Walsh was detained after being charged with attempted murder and, while experiencing delusions, refused food and drink with the stated intention of dying. He was transferred between HMP Highdown and HMP Belmarsh, where he was isolated in a single cell for 23½ hours a day and later died by hanging. The principal concerns were failures in communication and information-sharing between police, mental health, court and prison services, inadequate mental health assessment, and inadequate assessment of his fitness for segregation and suicide risk.

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 HCRG Care Ltd; that does not assign responsibility.
PFD Monitor interpretation
Failure to consider the whole person and reconcile or communicate missing and discordant information during proforma completion
Wider context from the report
“There appeared to be a focus by individuals on completing the proforma or questionnaire required by the system, by rote with either no time to consider the whole person, or no sense that it was their responsibility to consider missing or discordant information or to be proactive in communicating gaps in knowledge or concerns. From the evidence of a number of witnesses, the pattern of communication was not exceptional in this instance but reflected what usually happened. ”
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 HCRG Care Ltd; that does not assign responsibility.
PFD Monitor interpretation
Failure of detained organisations to pass risk information consistently between one another
Wider context from the report
“There was no agreed system for transfer of health care information from police station or court, or from either to prison. There was no functioning and consistent system of passing risk information from one detained organization to another. There was not agreement whether there just was a duty to pass the information or if it was not in possession, whether there was also one to ask for it and if so which individual bore that responsibility. ”
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 HCRG Care Ltd; that does not assign responsibility.
PFD Monitor interpretation
Inadequate nurse assessment of fitness for segregation
Wider context from the report
“3. That the inadequacy of the nurse assessment of fitness for segregation in HMP Highdown (see m) above) is a risk. ████████ was not ACCT trained and it appeared that he was unaware of PSI 1700. The inadequacy may reflect individual or wider weaknesses in assessment or choice of assessors that mean that prisoners go to segregation when they should be in the health care wing, or that they go without observation, when they should be on an ACCT and receive extra support. ”
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 HCRG Care Ltd; that does not assign responsibility.
PFD Monitor interpretation
Lack of an agreed system for transferring health care information from police stations or courts to prisons
Wider context from the report
“There was no agreed system for transfer of health care information from police station or court, or from either to prison. There was no functioning and consistent system of passing risk information from one detained organization to another. There was not agreement whether there just was a duty to pass the information or if it was not in possession, whether there was also one to ask for it and if so which individual bore that responsibility. ”
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 HCRG Care Ltd; that does not assign responsibility.
PFD Monitor interpretation
Inadequate standard of Mental Health Act assessments
Wider context from the report
“2. That the standard of Mental Health Act assessments by these individuals needs to be improved, and, given all three were in complete agreement, that also training and provision for MHA assessments in police stations more widely may need to be reviewed. ”
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 HCRG Care Ltd; that does not assign responsibility.
PFD Monitor interpretation
Lack of clear responsibility for passing or seeking relevant information
Wider context from the report
“There was no agreed system for transfer of health care information from police station or court, or from either to prison. There was no functioning and consistent system of passing risk information from one detained organization to another. There was not agreement whether there just was a duty to pass the information or if it was not in possession, whether there was also one to ask for it and if so which individual bore that responsibility. ”
Open source report
8 Dec2015
South London
Concerns raised2
1. Failure to assess emergency department patients consistently regardless of mode of transport
2. Insufficient qualification for assessment of urgent care patients
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

Madhumita Mandal · 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

Madhumita Mandal became unwell and attended Croydon University Hospital on 7 September 2013, where the inquest recorded multiple organ failure due to sepsis associated with a ruptured endometriotic ovarian cyst. The principal concerns were delays in assessment and treatment, including initial streaming by a receptionist without medical training, and failures in clinical supervision. The report also raised concerns about differing assessment based on whether patients arrived by ambulance.

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 HCRG Care Ltd; that does not assign responsibility.
PFD Monitor interpretation
Failure to assess emergency department patients consistently regardless of mode of transport
Wider context from the report
“Mrs Mandal’s death also raises questions about the use of ambulance services. A difference in assessment of patients based upon their mode of transport to the emergency department may encourage patients to err on the side of calling an ambulance. ”
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 HCRG Care Ltd; that does not assign responsibility.
PFD Monitor interpretation
Insufficient qualification for assessment of urgent care patients
Wider context from the report
“Mrs Mandal was taken to Croydon University Hospital by her husband. Virgin Care was contracted by the Croydon Clinical Commissioning Group to provide urgent care services, and to stream adult patients arriving at the emergency department. A streaming model was followed by a receptionist who had no medical training and who performed no medical observations. This led to a delay of about an hour before Mrs Mandal was seen by any qualified healthcare professional, by which time her condition was critical. The streaming model had been approved and commissioned in the contract as recommended by an NHS body called the Emergency Care Intensive Support Team. The system at Croydon has changed since Mrs Mandal’s death but concerns remain about the level of qualification for assessment of patients, and there may be lessons for other Trusts who contract out the provision of urgent care. ”
Open source report
2 Feb2015
Norfolk
Concerns raised2
1. Failure to ensure Code Blue responders know where to go
2. Insufficient availability of recently CPR-trained Prison Officers for emergencies
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

DARREN WRIGHT · 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

Darren Wright, aged 35, was found dead in his cell at HMP Norwich on 3 November 2013 after having been admitted to prison in September 2013. The report identified concerns about inconsistent sharing and access to information, the response to a Code Blue notification, and gaps in recent CPR training among attending prison officers.

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 HCRG Care Ltd; that does not assign responsibility.
PFD Monitor interpretation
Failure to ensure Code Blue responders know where to go
Wider context from the report
“(1) On receiving Code Blue notification the Staff Nurse did not know where to go and had to call on her radio to be found and then taken to the cell; ”
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 HCRG Care Ltd; that does not assign responsibility.
PFD Monitor interpretation
Insufficient availability of recently CPR-trained Prison Officers for emergencies
Wider context from the report
“(2) The Prison Officers attending Mr Wright had not had recent CPR training. It is understood that due to a lack of resources, CPR training has had to be allocated to certain members of staff only. This will result in gaps in CPR-trained Officers available and able to attend emergencies. ”
Open source report
27 Oct2014
Surrey
Concerns raised4
1. Failure to retain complete primary source data within the Phoenix Programme
2. Open and accessible ligature points within prisoner cells
3. Failure to ensure multidisciplinary attendance or input at ACCT reviews
1. Failure to record significant medical events in prisoner non-medical records accessible to discipline staff
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

Chrylin Angela Maria Norrell-Goldsmith · 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

Chrylin Angela Maria Norrell-Goldsmith was found shortly before midnight on 26 July 2013, partially suspended by a ligature in her cell at HMP Downview. CPR and subsequent paramedic efforts were unsuccessful, and the jury concluded that she took her own life. The principal concerns included exposed pipework in the cell, multidisciplinary input at ACCT reviews, retention of primary source data in the Phoenix Programme, and recording significant medical events in records accessible to prison discipline staff.

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 HCRG Care Ltd; that does not assign responsibility.
PFD Monitor interpretation
Failure to retain complete primary source data within the Phoenix Programme
Wider context from the report
“3. Retention of Primary Source Data within the Phoenix Programme Consideration should be given to ensuring that all primary source data (ie data provided by the prisoner to the therapist), should be kept either in hard copy format or by way of faithfully recoding all the detail contained therein on the prisoner’s System One record. ”
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 HCRG Care Ltd; that does not assign responsibility.
PFD Monitor interpretation
Open and accessible ligature points within prisoner cells
Wider context from the report
“1. Open pipe work within the cell Whilst it may not be possible to remove all potential ligature points within a cell, removal of easily accessible and obvious ligature points may serve to reduce the risk of self harm and suicide to vulnerable prisoners. ”
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 HCRG Care Ltd; that does not assign responsibility.
PFD Monitor interpretation
Failure to ensure multidisciplinary attendance or input at ACCT reviews
Wider context from the report
“2. Multi-Disciplinary Attendance / Input at ACCT Reviews Consideration should be given to ensuring that all staff, including prison staff, healthcare staff and In Reach staff understand the importance of requiring and providing multi-disciplinary attendance, or alternatively, multi-disciplinary input at all ACCT reviews. ”
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 HCRG Care Ltd; that does not assign responsibility.
PFD Monitor interpretation
Failure to record significant medical events in prisoner non-medical records accessible to discipline staff
Wider context from the report
“4. Recording Significant Medical Events on a prisoner’s Non-medical Records Consideration should be given to ensuring that all members of healthcare and In Reach staff working within a prison environment record all significant medical events that may impact upon a prisoner’s risk assessment for self-harm or suicide in a place or manner that is readily accessible to the discipline staff at the prison, in addition to any entry made in respect thereof in the System One record. ”
Open source report

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised6

Failure to consider the whole person and reconcile or communicate missing and discordant information during proforma completion

Failure of detained organisations to pass risk information consistently between one another

Inadequate nurse assessment of fitness for segregation

Lack of an agreed system for transferring health care information from police stations or courts to prisons

Inadequate standard of Mental Health Act assessments

Lack of clear responsibility for passing or seeking relevant information

Concerns raised2

Failure to assess emergency department patients consistently regardless of mode of transport

Insufficient qualification for assessment of urgent care patients

Concerns raised2

Failure to ensure Code Blue responders know where to go

Insufficient availability of recently CPR-trained Prison Officers for emergencies

Concerns raised4

Failure to retain complete primary source data within the Phoenix Programme

Open and accessible ligature points within prisoner cells

Failure to ensure multidisciplinary attendance or input at ACCT reviews

Failure to record significant medical events in prisoner non-medical records accessible to discipline staff