12 Jan 2026 STUART CHRISTOPHER JAMES BERRY · Prevention of Future Deaths report Essex
View report summary
Concerns raised 14 Failure to share critical suicide-risk information with prison staff View source Failure of liaison with external specialist substance misuse services View source Failure of internal multidisciplinary joint working View source Failure to update and document risk assessments View source Failure to document self-harm and suicide risk in clinical records View source Failure in HCRG staff training View source Failure to update and document care plans View source Failure to make urgent mental health referrals View source Failure of HCRG monitoring, supervision and quality assurance View source Failure of CMHT and Care Coordinator performance under the Care Programme Approach View source Failure to communicate with families and gather collateral information View source Inadequate national prison officer training for suicide risk assessment View source Failure to cost structural mitigation of accessible window-bar ligature points View source Inadequate electronic record documentation View source See 11 more concerns
Responses linked to these concerns
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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
STUART CHRISTOPHER JAMES BERRY · 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
STUART CHRISTOPHER JAMES BERRY, who had a history of mental health issues and significant cocaine misuse, was remanded to HMP Chelmsford on 27 January 2024 after expressing an intention to end his life. He was found suspended in his cell about seven hours after arrival and died at Broomfield Hospital on 1 February 2024; the medical cause of death was hanging and the jury concluded suicide. The principal concerns included failures in mental-health care, communication and risk documentation, failure to share information about his extreme suicide risk, inadequate assessment and supervision in prison, and the accessibility of cell-window ligature points.
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 Services Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure to share critical suicide-risk information with prison staff
Wider context from the report “In addition to failing to share crucial and obviously relevant information regarding Mr Berry’s extreme risk of suicide provided by the CPN at Court with prison staff , the jury found that the reception nurse, in the context of the clear information known to her, failed to: (a) document his risk of self-harm and suicide in the Systm One records and (b) failed to refer Mr Berry, that day, for an urgent review by the Mental Health team.
CONCERN: Such comprehensive shortcomings in performance in respect of information sharing , conduct of assessments, basic documentation and escalation/referral on to relevant colleagues indicates (a) a failure in training of a very concerning kind, alongside (b) a failure in HCRG monitoring of standards, supervision and quality assurance processes to identify and address such extensive failures in performance.
” 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 Services Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure of liaison with external specialist substance misuse services
Wider context from the report “CONCERN: During Mr Berry’s inquest, once again, many of the continuing failings under precisely the themes identified in the 2024 ‘Thematic Review’ and in PFDR responses prior to that review as well as in the period since that Review, have been identified as having informed the causative features contributing to the death of a patient under EPUT’s care. In my opinion, the actions taken by EPUT to date to address the acknowledged failings reflected under the themes and issues referred to above have been, and remain, inadequate and incomplete, specifically:
(a) Failures in the performance of the CMHT and the allocated Care Coordinator as required under the Care Programme Approach (CPA) and as mandated by EPUT policy. These failures indicated significant human error not detected by an insufficiently robust system and not therefore corrected prior to the death:
(b) Failures in Care Planning: specifically, a failure to appropriately up-date and document matters relating to Mr Berry’s Care Plan consistent with Trust policy.
(c) Failures in Risk Assessments: specifically, failures to appropriately up-date and document matters relating to Mr Berry’s risk assessment consistent with Trust policy.
(d) Failures in Documentation: in a number of acknowledged respects the electronic records were inadequate - and inconsistent with EPUT policy.
(e) Failure of joint working internally: the CC did not attempt to escalate or consult with EPUT colleagues via the regular weekly MTD meeting or any other type of Professionals’ Meeting.
(f) Failure of joint working externally : the CC did not liaise at all with the external specialist substance misuse team , even though the cocaine misuse was a central aspect of his presentation and mental health deterioration.
(g) Failures in Communication within and between teams as above but also, crucially, including a failure to appropriately liaise with the deceased’s Family to gather collateral information and to provide a carer’s assessment and/or support to Mr Berry’s family.
” 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 Services Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure of internal multidisciplinary joint working
Wider context from the report “CONCERN: During Mr Berry’s inquest, once again, many of the continuing failings under precisely the themes identified in the 2024 ‘Thematic Review’ and in PFDR responses prior to that review as well as in the period since that Review, have been identified as having informed the causative features contributing to the death of a patient under EPUT’s care. In my opinion, the actions taken by EPUT to date to address the acknowledged failings reflected under the themes and issues referred to above have been, and remain, inadequate and incomplete, specifically:
(a) Failures in the performance of the CMHT and the allocated Care Coordinator as required under the Care Programme Approach (CPA) and as mandated by EPUT policy. These failures indicated significant human error not detected by an insufficiently robust system and not therefore corrected prior to the death:
(b) Failures in Care Planning: specifically, a failure to appropriately up-date and document matters relating to Mr Berry’s Care Plan consistent with Trust policy.
(c) Failures in Risk Assessments: specifically, failures to appropriately up-date and document matters relating to Mr Berry’s risk assessment consistent with Trust policy.
(d) Failures in Documentation: in a number of acknowledged respects the electronic records were inadequate - and inconsistent with EPUT policy.
(e) Failure of joint working internally : the CC did not attempt to escalate or consult with EPUT colleagues via the regular weekly MTD meeting or any other type of Professionals’ Meeting.
(f) Failure of joint working externally: the CC did not liaise at all with the external specialist substance misuse team, even though the cocaine misuse was a central aspect of his presentation and mental health deterioration.
(g) Failures in Communication within and between teams as above but also, crucially, including a failure to appropriately liaise with the deceased’s Family to gather collateral information and to provide a carer’s assessment and/or support to Mr Berry’s family.
” 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 Services Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure to update and document risk assessments
Wider context from the report “CONCERN: During Mr Berry’s inquest, once again, many of the continuing failings under precisely the themes identified in the 2024 ‘Thematic Review’ and in PFDR responses prior to that review as well as in the period since that Review, have been identified as having informed the causative features contributing to the death of a patient under EPUT’s care. In my opinion, the actions taken by EPUT to date to address the acknowledged failings reflected under the themes and issues referred to above have been, and remain, inadequate and incomplete, specifically:
(a) Failures in the performance of the CMHT and the allocated Care Coordinator as required under the Care Programme Approach (CPA) and as mandated by EPUT policy. These failures indicated significant human error not detected by an insufficiently robust system and not therefore corrected prior to the death:
(b) Failures in Care Planning: specifically, a failure to appropriately up-date and document matters relating to Mr Berry’s Care Plan consistent with Trust policy.
(c) Failures in Risk Assessments: specifically, failures to appropriately up-date and document matters relating to Mr Berry’s risk assessment consistent with Trust policy .
(d) Failures in Documentation: in a number of acknowledged respects the electronic records were inadequate - and inconsistent with EPUT policy.
(e) Failure of joint working internally: the CC did not attempt to escalate or consult with EPUT colleagues via the regular weekly MTD meeting or any other type of Professionals’ Meeting.
(f) Failure of joint working externally: the CC did not liaise at all with the external specialist substance misuse team, even though the cocaine misuse was a central aspect of his presentation and mental health deterioration.
(g) Failures in Communication within and between teams as above but also, crucially, including a failure to appropriately liaise with the deceased’s Family to gather collateral information and to provide a carer’s assessment and/or support to Mr Berry’s family.
” 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 Services Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure to document self-harm and suicide risk in clinical records
Wider context from the report “In addition to failing to share crucial and obviously relevant information regarding Mr Berry’s extreme risk of suicide provided by the CPN at Court with prison staff, the jury found that the reception nurse, in the context of the clear information known to her, failed to: (a) document his risk of self-harm and suicide in the Systm One records and (b) failed to refer Mr Berry, that day, for an urgent review by the Mental Health team.
CONCERN: Such comprehensive shortcomings in performance in respect of information sharing, conduct of assessments, basic documentation and escalation/referral on to relevant colleagues indicates (a) a failure in training of a very concerning kind, alongside (b) a failure in HCRG monitoring of standards, supervision and quality assurance processes to identify and address such extensive failures in performance.
” 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 Services Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure in HCRG staff training
Wider context from the report “In addition to failing to share crucial and obviously relevant information regarding Mr Berry’s extreme risk of suicide provided by the CPN at Court with prison staff, the jury found that the reception nurse, in the context of the clear information known to her, failed to: (a) document his risk of self-harm and suicide in the Systm One records and (b) failed to refer Mr Berry, that day, for an urgent review by the Mental Health team.
CONCERN: Such comprehensive shortcomings in performance in respect of information sharing, conduct of assessments, basic documentation and escalation/referral on to relevant colleagues indicates (a) a failure in training of a very concerning kind , alongside (b) a failure in HCRG monitoring of standards, supervision and quality assurance processes to identify and address such extensive failures in performance.
” 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 Services Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure to update and document care plans
Wider context from the report “CONCERN: During Mr Berry’s inquest, once again, many of the continuing failings under precisely the themes identified in the 2024 ‘Thematic Review’ and in PFDR responses prior to that review as well as in the period since that Review, have been identified as having informed the causative features contributing to the death of a patient under EPUT’s care. In my opinion, the actions taken by EPUT to date to address the acknowledged failings reflected under the themes and issues referred to above have been, and remain, inadequate and incomplete, specifically:
(a) Failures in the performance of the CMHT and the allocated Care Coordinator as required under the Care Programme Approach (CPA) and as mandated by EPUT policy. These failures indicated significant human error not detected by an insufficiently robust system and not therefore corrected prior to the death:
(b) Failures in Care Planning: specifically, a failure to appropriately up-date and document matters relating to Mr Berry’s Care Plan consistent with Trust policy .
(c) Failures in Risk Assessments: specifically, failures to appropriately up-date and document matters relating to Mr Berry’s risk assessment consistent with Trust policy.
(d) Failures in Documentation: in a number of acknowledged respects the electronic records were inadequate - and inconsistent with EPUT policy.
(e) Failure of joint working internally: the CC did not attempt to escalate or consult with EPUT colleagues via the regular weekly MTD meeting or any other type of Professionals’ Meeting.
(f) Failure of joint working externally: the CC did not liaise at all with the external specialist substance misuse team, even though the cocaine misuse was a central aspect of his presentation and mental health deterioration.
(g) Failures in Communication within and between teams as above but also, crucially, including a failure to appropriately liaise with the deceased’s Family to gather collateral information and to provide a carer’s assessment and/or support to Mr Berry’s family.
” 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 Services Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure to make urgent mental health referrals
Wider context from the report “In addition to failing to share crucial and obviously relevant information regarding Mr Berry’s extreme risk of suicide provided by the CPN at Court with prison staff, the jury found that the reception nurse, in the context of the clear information known to her, failed to: (a) document his risk of self-harm and suicide in the Systm One records and (b) failed to refer Mr Berry, that day, for an urgent review by the Mental Health team .
CONCERN: Such comprehensive shortcomings in performance in respect of information sharing, conduct of assessments, basic documentation and escalation/referral on to relevant colleagues indicates (a) a failure in training of a very concerning kind, alongside (b) a failure in HCRG monitoring of standards, supervision and quality assurance processes to identify and address such extensive failures in performance.
” 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 Services Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure of HCRG monitoring, supervision and quality assurance
Wider context from the report “In addition to failing to share crucial and obviously relevant information regarding Mr Berry’s extreme risk of suicide provided by the CPN at Court with prison staff, the jury found that the reception nurse, in the context of the clear information known to her, failed to: (a) document his risk of self-harm and suicide in the Systm One records and (b) failed to refer Mr Berry, that day, for an urgent review by the Mental Health team.
CONCERN: Such comprehensive shortcomings in performance in respect of information sharing, conduct of assessments, basic documentation and escalation/referral on to relevant colleagues indicates (a) a failure in training of a very concerning kind, alongside (b) a failure in HCRG monitoring of standards, supervision and quality assurance processes to identify and address such extensive failures in performance.
” 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 Services Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure of CMHT and Care Coordinator performance under the Care Programme Approach
Wider context from the report “CONCERN: During Mr Berry’s inquest, once again, many of the continuing failings under precisely the themes identified in the 2024 ‘Thematic Review’ and in PFDR responses prior to that review as well as in the period since that Review, have been identified as having informed the causative features contributing to the death of a patient under EPUT’s care. In my opinion, the actions taken by EPUT to date to address the acknowledged failings reflected under the themes and issues referred to above have been, and remain, inadequate and incomplete, specifically:
(a) Failures in the performance of the CMHT and the allocated Care Coordinator as required under the Care Programme Approach (CPA) and as mandated by EPUT policy. These failures indicated significant human error not detected by an insufficiently robust system and not therefore corrected prior to the death :
(b) Failures in Care Planning: specifically, a failure to appropriately up-date and document matters relating to Mr Berry’s Care Plan consistent with Trust policy.
(c) Failures in Risk Assessments: specifically, failures to appropriately up-date and document matters relating to Mr Berry’s risk assessment consistent with Trust policy.
(d) Failures in Documentation: in a number of acknowledged respects the electronic records were inadequate - and inconsistent with EPUT policy.
(e) Failure of joint working internally: the CC did not attempt to escalate or consult with EPUT colleagues via the regular weekly MTD meeting or any other type of Professionals’ Meeting.
(f) Failure of joint working externally: the CC did not liaise at all with the external specialist substance misuse team, even though the cocaine misuse was a central aspect of his presentation and mental health deterioration.
(g) Failures in Communication within and between teams as above but also, crucially, including a failure to appropriately liaise with the deceased’s Family to gather collateral information and to provide a carer’s assessment and/or support to Mr Berry’s family.
” 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 Services Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate with families and gather collateral information
Wider context from the report “CONCERN: During Mr Berry’s inquest, once again, many of the continuing failings under precisely the themes identified in the 2024 ‘Thematic Review’ and in PFDR responses prior to that review as well as in the period since that Review, have been identified as having informed the causative features contributing to the death of a patient under EPUT’s care. In my opinion, the actions taken by EPUT to date to address the acknowledged failings reflected under the themes and issues referred to above have been, and remain, inadequate and incomplete, specifically:
(a) Failures in the performance of the CMHT and the allocated Care Coordinator as required under the Care Programme Approach (CPA) and as mandated by EPUT policy. These failures indicated significant human error not detected by an insufficiently robust system and not therefore corrected prior to the death:
(b) Failures in Care Planning: specifically, a failure to appropriately up-date and document matters relating to Mr Berry’s Care Plan consistent with Trust policy.
(c) Failures in Risk Assessments: specifically, failures to appropriately up-date and document matters relating to Mr Berry’s risk assessment consistent with Trust policy.
(d) Failures in Documentation: in a number of acknowledged respects the electronic records were inadequate - and inconsistent with EPUT policy.
(e) Failure of joint working internally: the CC did not attempt to escalate or consult with EPUT colleagues via the regular weekly MTD meeting or any other type of Professionals’ Meeting.
(f) Failure of joint working externally: the CC did not liaise at all with the external specialist substance misuse team, even though the cocaine misuse was a central aspect of his presentation and mental health deterioration.
(g) Failures in Communication within and between teams as above but also, crucially, including a failure to appropriately liaise with the deceased’s Family to gather collateral information and to provide a carer’s assessment and/or support to Mr Berry’s family.
” 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 Services Ltd; that does not assign responsibility.
PFD Monitor interpretation Inadequate national prison officer training for suicide risk assessment
Wider context from the report “CONCERN: In the context of the finding of the jury of a gross failure to ensure that Mr Berry was, in all the circumstances as known to the prison staff, subject to Constant Supervision, I am concerned that inadequate national training contributed to an over-reliance by prison staff on the subjective perception of an ‘improvement’ in a prisoner’s transient presentation and demeanour over obvious and grave documented risk factors when assessing risk and setting observation levels. The reassurance provided by Mr Berry, (according to the Supervising Officer) appears to have been dangerously misleading and uncritically accepted notwithstanding the clear, high risk of suicide Mr Berry presented. This, in turn, gives rise to my concern (in the light of the evidence provided by the POELT trainer) that the exceptionally short time allocated in national prison officer training to equip officers with the requisite skills to assess, identify and records triggers, risk factors and protective factors is wholly inadequate.
” 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 Services Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure to cost structural mitigation of accessible window-bar ligature points
Wider context from the report “CONCERN: A further concern raised by the evidence relates to the lack of any attempt to cost structural cell improvements to mitigate , at least in some cells on each wing, the most obvious of ligature points in the Victorian Prison estates’ cells, namely the readily accessible fixed bars at the windows. Whilst other less obvious ligature points are potentially available in cells, all the (multiple) self-inflicted ligature related deaths at HMP Chelmsford in recent years have exclusively involved the use of the window bars.
The HMPPS Prison Group Director for Hertfordshire, Essex and Suffolk prisons undertook, following his evidence that such costings had not even been sought to date, to now ensure that such an exercise is undertaken. However, the concern remains that this is a national issue in relation to all Victorian or equivalent prisons and that absent even a costing exercise, steps to mitigate this serious, obvious and continuing risk will not be addressed .
” 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 Services Ltd; that does not assign responsibility.
PFD Monitor interpretation Inadequate electronic record documentation
Wider context from the report “CONCERN: During Mr Berry’s inquest, once again, many of the continuing failings under precisely the themes identified in the 2024 ‘Thematic Review’ and in PFDR responses prior to that review as well as in the period since that Review, have been identified as having informed the causative features contributing to the death of a patient under EPUT’s care. In my opinion, the actions taken by EPUT to date to address the acknowledged failings reflected under the themes and issues referred to above have been, and remain, inadequate and incomplete, specifically:
(a) Failures in the performance of the CMHT and the allocated Care Coordinator as required under the Care Programme Approach (CPA) and as mandated by EPUT policy. These failures indicated significant human error not detected by an insufficiently robust system and not therefore corrected prior to the death:
(b) Failures in Care Planning: specifically, a failure to appropriately up-date and document matters relating to Mr Berry’s Care Plan consistent with Trust policy.
(c) Failures in Risk Assessments: specifically, failures to appropriately up-date and document matters relating to Mr Berry’s risk assessment consistent with Trust policy.
(d) Failures in Documentation: in a number of acknowledged respects the electronic records were inadequate - and inconsistent with EPUT policy.
(e) Failure of joint working internally: the CC did not attempt to escalate or consult with EPUT colleagues via the regular weekly MTD meeting or any other type of Professionals’ Meeting.
(f) Failure of joint working externally: the CC did not liaise at all with the external specialist substance misuse team, even though the cocaine misuse was a central aspect of his presentation and mental health deterioration.
(g) Failures in Communication within and between teams as above but also, crucially, including a failure to appropriately liaise with the deceased’s Family to gather collateral information and to provide a carer’s assessment and/or support to Mr Berry’s family.
” Open source report
6 Feb 2024 Mark PRYOR · Prevention of Future Deaths report Derby and Derbyshire
View report summary
Concerns raised 1 Lack of sufficient training for health care professionals working in police custody suites 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
Mark PRYOR · 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
Mark Pryor died at the emergency department of Royal Derby Hospital on 5 September 2020 after suffering an alcohol-withdrawal-related seizure and cardiorespiratory arrest while in police custody. The inquest jury found deficiencies in the health care professionals’ assessment and treatment of his alcohol withdrawal that probably made more than a minimal contribution to his death. The report raises concerns that health care professionals may not receive sufficient training to practise effectively and safely in police custody suites.
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 Services Ltd; that does not assign responsibility.
PFD Monitor interpretation Lack of sufficient training for health care professionals working in police custody suites
Wider context from the report “I am concerned that Health Care Professionals (HCPs) may not be receiving sufficient and adequate training to enable them to practice effectively or safely in police custody suites. This is based on the evidence and findings in Mr Pryor’s inquest and my understanding that the training provided by HCRG may be very similar to that given by other providers of HCP police custody services nationally.
Clinical assessment and treatment is provided to police custody detainees by HCPs with the support of an on-call doctor. Typically there will be one HCP per shift. Nationally, HCP services are provided by a number of independent providers under contract to individual police forces. Professionals eligible to be recruited as HCPs (as taken from HCRG personal specification) are registered nurses (general or mental health), or paramedics with a minimum of two years post-qualification with NMC or HCPC registration and ‘nursing experience in the following: A&E, ITU, EAU, SAU, Nurse Practitioner, Practice Nurse, EAU, SAU (other nursing backgrounds will be considered)'.
Current training provided to newly appointed HCPs (by HCRG) consists of shadowing shifts with an experienced HCP, potentially for up to six or eight shifts; a two-day induction course; a medication related course of less than a day which includes a pass or fail test. There is also formal supervision and a three-month probationary period.
The two-day induction course covers the following topics: -
Day 1
Overview of the role of HCPs in custody; Consent, confidentiality and ethics – covering topics including the relevant laws, regulations and regulatory issues, the importance and limitations of concept, assessing capacity, nature of the HCPs dual responsibility and how it affects disclosure of sensitive information. and importance of record keeping; Fitness to detain – covering topics including the need to assess detainees for injuries, illness, and drug and alcohol problems, formulating a care plan in custody to manage risk and identifying those who are not fit to detain who may need alternative support; Fitness to interview / charge/ transfer / release – covering topics including a recap on assessing capacity and assessing, safeguards to prevent the risk of involuntary/false confessions, overview of illnesses that might be worsened by interview and facts to consider when assessing detainees’ fitness to release; Drugs and alcohol is police custody – covering topics including examination features of alcohol and/ or opiate intoxication, examination features of alcohol or opiate withdrawal, key assessment details in the detainee with alcohol dependence, treatment of alcohol / opiate withdrawal in police custody; Mental health in custody - covering topics including the relevant sections of the Mental Health Act, the overlap of learning difficulties with mental health in police custody, the role of liaison and diversion (L&D) teams and the approved mental health professional (AMHP) and when to refer to specialist services; Mental state examination (MSE) – covering topics including purpose of MSE, format of MSE, communicating MSE findings and risk assessments.
Day 2
Forensic science and samples – covering topics including understanding Locard’s Principle, which offences may trigger sample requests, taking non intimate and intimate samples and relevant procedural steps; Traffic Medicine – covering relevant procedures under the Road Traffic Act; Restraint, TASER and irritant sprays – covering an overview of different types of restraint and when a detainee may need hospital following restraint; Documentation of injury – covering how to take history for injuries, how to describe, document and classify injuries; Statement writing – covering topics including overview on preparing a witness statement, format of a witness statement and information required to complete a statement and importance of good clinical notation on the assessment forms provided in custody.
I have reproduced the summary of training, which was given in evidence at the inquest, to illustrate that there are obviously a very extensive number of topics which are listed to be covered.
I find it difficult to see that necessary training can be given within the specified time to equip a paramedic or nurse who is fresh to the custody setting to practice effectively and safely. The inquest heard evidence from the more experienced HCP that when she started, with a different provider some eight years prior, she had six weeks classroom-based training before she commenced full duties as an HCP. The injunction also heard that The Faculty of Forensic & Legal Medicine recommends a five-day induction course for HCPs.
” Open source report
Concerns raised 2 Lack of communication between district nursing teams, family members and other agencies involved View source Inadequate availability of nursing 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
Derek Reginald Smith · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Derek Reginald Smith, who was bedbound and unable to manage his care needs, died at home on 21 December 2017 from aspiration pneumonia. He had developed a severe pressure sore, and the report raised concerns about limited communication between district nurses, family members and possibly carers, as well as the availability of nursing records and delays in treatment decisions.
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 Services Ltd; that does not assign responsibility.
PFD Monitor interpretation Lack of communication between district nursing teams, family members and other agencies involved
Wider context from the report “It became apparent at the inquest that there was very little communication between the District Nursing team who attended Mr Smith and family members (and possibly little communication with the attending carers as well) . There was also an issue regarding the availability of nursing records as well. It may be that Mr Smith’s death could not be prevented but there could have been opportunities for helpful interventions by the family and earlier decision making regarding Mr Smith’s treatment. Suitable communication could well be a significant factor in other cases. I wonder if systems could be changed to ensure better communication between the District Nursing team, family members and other agencies involved.
” 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 Services Ltd; that does not assign responsibility.
PFD Monitor interpretation Inadequate availability of nursing records
Wider context from the report “It became apparent at the inquest that there was very little communication between the District Nursing team who attended Mr Smith and family members (and possibly little communication with the attending carers as well). There was also an issue regarding the availability of nursing records as well. It may be that Mr Smith’s death could not be prevented but there could have been opportunities for helpful interventions by the family and earlier decision making regarding Mr Smith’s treatment. Suitable communication could well be a significant factor in other cases. I wonder if systems could be changed to ensure better communication between the District Nursing team, family members and other agencies involved.
” Open source report
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Addressed to “VIRGIN CARE SERVICES LIMITED”, a former name of HCRG Care Services Ltd.
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations