Concerns raised 4 Welfare-check instructions failing to require visual checks of prisoners View source Failure to ensure critical welfare-check instructions are received and understood by affected staff View source Failure to ensure removal of coverings from cell-door observation panels View source Failure to maintain and monitor staff competence in opening an ACCT where required View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Johnpaul Digweed · 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
Johnpaul Digweed died by suicide by hanging in his cell at HMP Garth between 17:06 on 12 April 2024 and 11:31 on 13 April 2024. The concerns included failures to open an ACCT process after incidents of self-harm, inadequate assurance about staff training and information-sharing, and welfare observations not being carried out in accordance with prison procedures, including when observation panels were obscured.
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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Welfare-check instructions failing to require visual checks of prisoners
Wider context from the report “2. Evidence was heard that there is a regular practice of prisoner's covering their observation panels in their cell doors at HMP Garth. Despite Governor's Orders and staff instructions being in place requiring staff to take steps to ensure any inundation is removed, this was not being adhered to. Evidence was heard that some staff were not aware of the instructions which were issued by email. As a result, the orders and notices have been updated and reissued by email clarifying expectations in relation to welfare checks and steps requires if observations panels are obscured. However, no assurance could be given that staff had read and understood the instructions or that there was any system outside the email system to ensure important information is cascaded and seen by affected staff. In addition, whilst the amended instructions confirm a verbal response is mandatory for welfare checks, they do not explicitly state a visual check of the prisoner is also required . Given your responsibility for HMP Garth, I consider you are responsible for taking the action that is required to prevent 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure critical welfare-check instructions are received and understood by affected staff
Wider context from the report “2. Evidence was heard that there is a regular practice of prisoner's covering their observation panels in their cell doors at HMP Garth. Despite Governor's Orders and staff instructions being in place requiring staff to take steps to ensure any inundation is removed, this was not being adhered to. Evidence was heard that some staff were not aware of the instructions which were issued by email . As a result, the orders and notices have been updated and reissued by email clarifying expectations in relation to welfare checks and steps requires if observations panels are obscured. However, no assurance could be given that staff had read and understood the instructions or that there was any system outside the email system to ensure important information is cascaded and seen by affected staff . In addition, whilst the amended instructions confirm a verbal response is mandatory for welfare checks, they do not explicitly state a visual check of the prisoner is also required. Given your responsibility for HMP Garth, I consider you are responsible for taking the action that is required to prevent 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure removal of coverings from cell-door observation panels
Wider context from the report “2. Evidence was heard that there is a regular practice of prisoner's covering their observation panels in their cell doors at HMP Garth. Despite Governor's Orders and staff instructions being in place requiring staff to take steps to ensure any inundation is removed, this was not being adhered to . Evidence was heard that some staff were not aware of the instructions which were issued by email. As a result, the orders and notices have been updated and reissued by email clarifying expectations in relation to welfare checks and steps requires if observations panels are obscured. However, no assurance could be given that staff had read and understood the instructions or that there was any system outside the email system to ensure important information is cascaded and seen by affected staff. In addition, whilst the amended instructions confirm a verbal response is mandatory for welfare checks, they do not explicitly state a visual check of the prisoner is also required. Given your responsibility for HMP Garth, I consider you are responsible for taking the action that is required to prevent 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain and monitor staff competence in opening an ACCT where required
Wider context from the report “1. Evidence was heard that despite several staff being aware of incidents of self-harm involving a prisoner at HMP Garth an Assessment, Care in Custody Teamwork process (ACCT) was not opened . Whilst evidence was provided that staff are trained as part of their induction program and that training materials is available to staff, no assurance could be given that there was any ongoing mandatory refresher training or any system in place to monitor understanding that every member of staff is responsible for opening an ACCT where required . Given your responsibility for HMP Garth, I consider you are responsible for taking the action that is required to prevent future deaths
” 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 daily mandatory knowledge-check sessions for operational and non-operational staff, recording attendance, completion and understanding to reinforce ACCT and welfare-check practice.
Verbatim wording from the response “The prison have begun introducing daily knowledge check sessions for both operational and non-operational staff, and additional staffing resources are being secured to support the delivery of this initiative. Attendance and completion of the knowledge check sessions will be required and formally recorded, with staff providing written confirmation they have attended a session, and that the content is understood. A training log will be maintained by the prison’s Learning and Capabilities Team to monitor attendance and completion rates.” Source location Response from HM Prison and Probation Service
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 Make hard copies of current staff notices available on every residential wing for reference and use during staff briefings.
Verbatim wording from the response “To ensure that staff notices are accessible to all operational staff, hard copies of current notices will be made available on each residential wing so they can be referenced by staff at all times and used by managers and supervising officers during staff briefings.” Source location Response from HM Prison and Probation Service
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 Reissue the Governor’s Order reminding staff of mandatory instructions for prisoner wellbeing and responding to blocked observation panels.
Verbatim wording from the response “Furthermore, to reinforce local guidance a Governor’s Order has been reissued reminding staff of the mandatory instructions in place in line with PSI 75/2011, and the requirement to ensure the wellbeing of prisoners and action to be taken should a blocked observation panel be discovered.” Source location Response from HM Prison and Probation Service
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 Add read-and-understood acknowledgements to staff-notice emails and create a response database to identify non-responders for follow-up.
Verbatim wording from the response “In addition, all emails containing staff notices will include an acknowledgement function requiring recipients to confirm they have read and understood the content of the notice. This acknowledgement will be used to create a database to record which members of staff have responded, and aid the identification of those who have not thus enabling appropriate follow-up action where necessary.” Source location Response from HM Prison and Probation Service
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 Secure additional staffing resources to support delivery of the daily knowledge-check sessions.
Verbatim wording from the response “The prison have begun introducing daily knowledge check sessions for both operational and non-operational staff, and additional staffing resources are being secured to support the delivery of this initiative. Attendance and completion of the knowledge check sessions will be required and formally recorded, with staff providing written confirmation they have attended a session, and that the content is understood. A training log will be maintained by the prison’s Learning and Capabilities Team to monitor attendance and completion rates.” Source location Response from HM Prison and Probation Service
Open published response
21 May 2026 George Edward James Haldenby · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 4 Delays in processing hospital-issued FP10 prescriptions in prisons without 24-hour healthcare provision View source Incomplete availability of critical medications held in prison View source Lack of local policy or process for managing out-of-hours FP10 prescriptions View source Lack of mandatory refresher training in first aid and CPR for prison staff View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
George Edward James Haldenby · 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
George Edward James Haldenby was a serving prisoner with severe heart failure who collapsed at HMP The Verne on 29 January 2022 and died that day at Dorset County Hospital. The report identifies delays in receiving an increased dose of Furosemide, and a delay in recognising the collapse and starting CPR, as substantive concerns. It also raises concerns about the absence of regular refresher training in first aid and CPR and the lack of a clear process for handling hospital prescriptions issued outside prison healthcare hours.
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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Delays in processing hospital-issued FP10 prescriptions in prisons without 24-hour healthcare provision
Wider context from the report “In prisons without 24 hour healthcare provision, if a prisoner receives treatment at a hospital and is issued with a medication prescription on a FP10 form, this cannot be processed at the prison in the absence of a doctor or prescribing nurse , and pharmacies in hospitals are not always open 24 hours a day for it to be dispensed as TTO medication. This means there will be a delay in prisoners receiving necessary and lifesaving medication over a weekend or bank holiday period until staff are in the prison who can action the prescription.
” 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Incomplete availability of critical medications held in prison
Wider context from the report “Whilst at HMP The Verne there is now a duty Doctor who can be called upon out of hours to progress such prescriptions, there is a lack of local policy or process to ensure the prison and healthcare staff have an understanding of how to deal with the situation should a FP10 be issued outside of hours when a prescribing health professional is not available in the prison to ensure a prisoner receives necessary medications without delay. Although critical medications are held at the prison in a locked cabinet, not all medication are included and Furosemide, which was critical in George’s care, is one of those that is not held by the prison as a critical medicine .
” 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Lack of local policy or process for managing out-of-hours FP10 prescriptions
Wider context from the report “Whilst at HMP The Verne there is now a duty Doctor who can be called upon out of hours to progress such prescriptions, there is a lack of local policy or process to ensure the prison and healthcare staff have an understanding of how to deal with the situation should a FP10 be issued outside of hours when a prescribing health professional is not available in the prison to ensure a prisoner receives necessary medications without delay. Although critical medications are held at the prison in a locked cabinet, not all medication are included and Furosemide, which was critical in George’s care, is one of those that is not held by the prison as a critical medicine.
” 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Lack of mandatory refresher training in first aid and CPR for prison staff
Wider context from the report “After prison officers and prison staff carry out their induction training which covers basic first aid training including the delivery of cardio pulmonary resuscitation (CPR), there is no further mandatory refresher training on first aid or CPR . During the evidence, a Custodial Manager at HMP the Verne stated that the last time he had first aid or CPR training was in 1991, 35 years ago, when he started as a prison officer. Whilst there is a requirement to have a duty first aider on site 24 hours a day, without all staff being suitably and regularly trained in signs of collapse and administering CPR , there could be a delay in delivering effective CPR as it may take time for the duty first aider to get to the prisoner, and a future death could occur.
” Open source report
7 Apr 2026 Mark Robert Smith · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 9 Failure to ensure truthful observation records View source Failure to maintain QEH staff awareness of the limits of prison healthcare View source Failure to coordinate prison discharge through an MDT and relevant prison healthcare liaison View source Failure to prescribe and administer medication at the correct dose View source Failure to ensure safe and clearly understood medication-system operation View source Failure to record the cell-entry escalation process in policy View source Failure to maintain prison and healthcare staff awareness of the cell-entry escalation process View source Failure to complete required patient observations View source Unavailability of larger disabled cells adapted for constant watch View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Mark Robert 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
Mark Robert Smith, who was detained at HMP Thameside, died after an epileptic seizure led to cardiac arrest. The report describes concerns about medication prescribing and administration, hospital-to-prison discharge and communication, access to his cell, observation arrangements and records, staffing, and the lack of equipment for resuscitation.
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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure truthful observation records
Wider context from the report “(5) I am concerned there were numerous missed and falsified observation entries in Mark’s case and how similar incidents can be prevented given the reliance on handwritten sheets being scanned onto the system at a later stage . I appreciate the efforts made with training and audits. (Practice Plus Group)
” 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain QEH staff awareness of the limits of prison healthcare
Wider context from the report “(2) I remain concerned a similar situation could arise as did in Mark’s case regarding a discharge back to prison from QEH without an MDT meeting despite repeated requests from prison healthcare and there could be a risk to life. I note PFD evidence provided regarding improved liaison between QEH and the prison GP but note no reference to liaison between QEH and the head of the healthcare in prison, who visited QEH twice in Mark’s case.
Further, as recently as 2025 an incident occurred when there was a lack of understanding at QEH around the limited provision in healthcare in prison . I am concerned as to how awareness of the limits of prison healthcare will be disseminated on a continuing basis to new and locum staff at QEH . (QEH and Practice Plus Group)
” 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to coordinate prison discharge through an MDT and relevant prison healthcare liaison
Wider context from the report “(2) I remain concerned a similar situation could arise as did in Mark’s case regarding a discharge back to prison from QEH without an MDT meeting despite repeated requests from prison healthcare and there could be a risk to life. I note PFD evidence provided regarding improved liaison between QEH and the prison GP but note no reference to liaison between QEH and the head of the healthcare in prison , who visited QEH twice in Mark’s case.
Further, as recently as 2025 an incident occurred when there was a lack of understanding at QEH around the limited provision in healthcare in prison. I am concerned as to how awareness of the limits of prison healthcare will be disseminated on a continuing basis to new and locum staff at QEH. (QEH and Practice Plus Group)
” 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to prescribe and administer medication at the correct dose
Wider context from the report “(1) The wrong dose of medication could be prescribed and/or administered with life threatening consequences. Albeit I have seen evidence of significant improvements in prescribing practice at HMP Thameside since 2019 (e.g HMIP report February 2026); as recently as 2024 to 2025 HMIP and IMB reports noted “significant risks with management of medicines” and “prescribing errors.” Whilst recent internal audits in 2025 show significant improvements, medication incidents (datix) are recorded in late 2025 and the principal pharmacist notes a very busy site with multiple prescriptions screened daily.
Further, during the inquest it proved difficult to establish how Systm 1 (the medical note system) operated and whether there were risks inherent in the system itself. For example, it was suggested the system would convert mg into ml or pre-populate entries such as 100ml, in contradiction to the subsequent PFD evidence provided. (Practice Plus Group)
” 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure safe and clearly understood medication-system operation
Wider context from the report “(1) The wrong dose of medication could be prescribed and/or administered with life threatening consequences. Albeit I have seen evidence of significant improvements in prescribing practice at HMP Thameside since 2019 (e.g HMIP report February 2026); as recently as 2024 to 2025 HMIP and IMB reports noted “significant risks with management of medicines” and “prescribing errors.” Whilst recent internal audits in 2025 show significant improvements, medication incidents (datix) are recorded in late 2025 and the principal pharmacist notes a very busy site with multiple prescriptions screened daily.
Further, during the inquest it proved difficult to establish how Systm 1 (the medical note system) operated and whether there were risks inherent in the system itself . For example, it was suggested the system would convert mg into ml or pre-populate entries such as 100ml , in contradiction to the subsequent PFD evidence provided. (Practice Plus Group)
” 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to record the cell-entry escalation process in policy
Wider context from the report “(3) Healthcare staff may be unable to enter a prisoner’s cell at night and monitor them in a situation which may not constitute a “medical emergency” but in which a patient nevertheless requires attention; a patient could decline and the situation become life threatening. I have received detail from Serco of “an escalation process” if Oscar 1 and Hotel 1 cannot agree about entry to a cell and I have been told this has been “recommunicated” to all staff. However, this is not recorded in a policy. I am concerned about awareness of the process for all prison and healthcare staff including on an ongoing basis. (Serco and Practice Plus Group).
” 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain prison and healthcare staff awareness of the cell-entry escalation process
Wider context from the report “(3) Healthcare staff may be unable to enter a prisoner’s cell at night and monitor them in a situation which may not constitute a “medical emergency” but in which a patient nevertheless requires attention; a patient could decline and the situation become life threatening. I have received detail from Serco of “an escalation process” if Oscar 1 and Hotel 1 cannot agree about entry to a cell and I have been told this has been “recommunicated” to all staff. However, this is not recorded in a policy. I am concerned about awareness of the process for all prison and healthcare staff including on an ongoing basis. (Serco and Practice Plus Group).
” 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to complete required patient observations
Wider context from the report “(5) I am concerned there were numerous missed and falsified observation entries in Mark’s case and how similar incidents can be prevented given the reliance on handwritten sheets being scanned onto the system at a later stage. I appreciate the efforts made with training and audits. (Practice Plus Group)
” 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Unavailability of larger disabled cells adapted for constant watch
Wider context from the report “(4) There are no larger disabled cells (which can accommodate hospital beds and wheelchairs) adapted to also facilitate a constant watch. Security concerns, in this might not be possible, and a similar situation might occur to that in Mark’s case. (HMPPS)
” Open source report
24 Mar 2026 Ronald William MEIKLE · Prevention of Future Deaths report Milton Keynes
View report summary
Concerns raised 16 Weak supervision and staff-prisoner engagement View source Failure to maintain a clear and current drug under the influence policy View source Delays or insufficiency in psychiatric assessment and proactive mental health review View source Failure to recognise suspected synthetic cannabinoid intoxication promptly during collapse response View source Insufficient staffing capacity View source Restricted prison regimes View source Insufficiently robust identification and management of prisoners remaining behind their door because of vulnerability View source Inadequate welfare observations View source Inconsistent identification, assessment, monitoring and response to prisoners under the influence of illicit substances View source Failure to escalate prisoners with cumulative vulnerability indicators into safer custody procedures View source Availability of illicit substances in custody View source Failure to reliably consolidate and share relevant prisoner risk information View source Failure to maintain unobstructed observation panels for effective visual welfare checks View source Delays in supplying material information relevant to death investigations and future-death prevention View source Failure to implement sufficient and sustained remedial action on identified prison safety concerns View source Failure to recognise IPP status as a material vulnerability requiring structured support and review View source See 13 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Ronald William MEIKLE · 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
Ronald William Meikle was found unresponsive in his single-occupancy cell at HMP Woodhill on 30 April 2024 and was pronounced dead at 09:43. The report identified concerns about illicit substances, inconsistent responses to suspected intoxication, fragmented information-sharing, inadequate welfare observations, management of self-isolation and vulnerability, absence of ACCT proceedings, mental-health input, emergency response, staffing, and recurring systemic problems at the prison.
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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Weak supervision and staff-prisoner engagement
Wider context from the report “Concern 10: Staffing, supervision and regime limitations
The evidence before the court, including wider inspection material, raised concern that staffing pressures, weak supervision, poor staff-prisoner engagement , restricted regimes, and inadequate welfare observations may materially increase the risk of undetected drug use, delayed discovery of collapsed prisoners and failure to identify vulnerable men in need of intervention.
” 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain a clear and current drug under the influence policy
Wider context from the report “Concern 2: Failure consistently to identify, record and respond to prisoners under the influence
The evidence showed concerns about the consistency with which prisoners suspected or found to be under the influence of illicit substances were identified, clinically assessed, monitored, referred to substance misuse services, and managed under prison and healthcare processes. There was evidence that episodes of apparent intoxication were not always met with a consistent healthcare response or documented follow-up. The head of service had an understanding of the drug under the influence policy that was starkly different to the written document . There had been multiple updates of the drug policy which were difficult to identify as to when the policy was updated / revised . I am concerned that prisoners at acute risk of overdose or deterioration may therefore not receive timely intervention.
” 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Delays or insufficiency in psychiatric assessment and proactive mental health review
Wider context from the report “Concern 8: Delay or insufficiency in mental health and psychiatric input
The evidence raised concern that prisoners with known vulnerabilities, substance misuse history and symptoms of deteriorating mental health may not always receive timely psychiatric assessment or sufficiently proactive mental health review . Delays in specialist assessment can increase the risk of unmanaged distress, relapse to substance use and death.
” 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise suspected synthetic cannabinoid intoxication promptly during collapse response
Wider context from the report “Concern 9: Emergency response to suspected synthetic cannabinoid collapse
The evidence raised concern about whether staff responding to collapse were adequately trained and equipped to consider synthetic cannabinoid intoxication promptly as a possible cause . Synthetic cannabinoid use can cause rapid deterioration and death. If staff do not recognise that possibility, there is a risk of delay in appropriate emergency action, clinical escalation and treatment .
” 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Insufficient staffing capacity
Wider context from the report “Concern 10: Staffing, supervision and regime limitations
The evidence before the court, including wider inspection material, raised concern that staffing pressures , weak supervision, poor staff-prisoner engagement, restricted regimes, and inadequate welfare observations may materially increase the risk of undetected drug use, delayed discovery of collapsed prisoners and failure to identify vulnerable men in need of intervention.
” 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Restricted prison regimes
Wider context from the report “Concern 10: Staffing, supervision and regime limitations
The evidence before the court, including wider inspection material, raised concern that staffing pressures, weak supervision, poor staff-prisoner engagement, restricted regimes , and inadequate welfare observations may materially increase the risk of undetected drug use, delayed discovery of collapsed prisoners and failure to identify vulnerable men in need of intervention.
” 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Insufficiently robust identification and management of prisoners remaining behind their door because of vulnerability
Wider context from the report “Concern 5: Management of self-isolation, debt, fear and vulnerability
The evidence suggested that Mr Meikle had vulnerabilities connected to self-isolation, debt, fear of other prisoners, possible coercion or bullying, mental ill-health, and substance misuse. I am concerned that the systems for identifying and managing prisoners who remain behind their door because of debt, fear, vulnerability or drug-related pressures were not sufficiently robust, coordinated or escalated .
” 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Inadequate welfare observations
Wider context from the report “Concern 10: Staffing, supervision and regime limitations
The evidence before the court, including wider inspection material, raised concern that staffing pressures, weak supervision, poor staff-prisoner engagement, restricted regimes, and inadequate welfare observations may materially increase the risk of undetected drug use, delayed discovery of collapsed prisoners and failure to identify vulnerable men in need of intervention.
” 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Inconsistent identification, assessment, monitoring and response to prisoners under the influence of illicit substances
Wider context from the report “Concern 2: Failure consistently to identify, record and respond to prisoners under the influence
The evidence showed concerns about the consistency with which prisoners suspected or found to be under the influence of illicit substances were identified, clinically assessed, monitored, referred to substance misuse services, and managed under prison and healthcare processes . There was evidence that episodes of apparent intoxication were not always met with a consistent healthcare response or documented follow-up . The head of service had an understanding of the drug under the influence policy that was starkly different to the written document. There had been multiple updates of the drug policy which were difficult to identify as to when the policy was updated / revised. I am concerned that prisoners at acute risk of overdose or deterioration may therefore not receive timely intervention.
” 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate prisoners with cumulative vulnerability indicators into safer custody procedures
Wider context from the report “Concern 6: Absence of ACCT despite identifiable indicators of vulnerability
The concern is not that ACCT documentation disclosed a missed risk factor, but that the available materials show Mr Meikle was not subject to ACCT proceedings, despite evidence shortly before death of self-isolation, debt-related vulnerability, known substance misuse and reduced engagement. This occurred in an establishment where HM Inspectorate of Prisons had already identified weaknesses in ACCT management and welfare checking during an unannounced inspection in 2023 and had issued an Urgent Notification which included reference to "frailties in ACCT case management". I later became aware of a second Urgent Notification issued in March 2026, shortly after completion of Mr Meikle's inquest that once again identified "frailties in ACCT case management". I am concerned that prisoners presenting with cumulative indicators of vulnerability may not be escalated into safer custody procedures when required , thereby increasing the risk that deteriorating welfare is not recognised or managed.
” 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Availability of illicit substances in custody
Wider context from the report “Concern 1: Availability of illicit substances in custody
The evidence indicated that illicit drugs ████████ were readily available within HMP Woodhill . Material before the court showed this was not an isolated issue but part of a wider and continuing prison safety problem at HMP Woodhill and likely other prisons . The availability of synthetic cannabinoids in custody creates a foreseeable risk of sudden collapse, respiratory compromise, cardiac arrest, psychosis, violence, self-harm and death.
” 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to reliably consolidate and share relevant prisoner risk information
Wider context from the report “Concern 3: Fragmented information-sharing and record keeping
The evidence demonstrated that relevant risk information was spread across multiple recording systems and was not always shared effectively between operational staff and clinical teams . This included information relevant to substance misuse, mental health, debt, bullying or coercion, self-isolation, intelligence about threats, recent presentation under the influence. Where critical safety information is held in separate systems and not reliably brought together , there is a foreseeable risk that warning signs will be missed and protective action delayed with obvious risk of harm or death.
” 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain unobstructed observation panels for effective visual welfare checks
Wider context from the report “Concern 4: Blocked observation panels and inadequate visual welfare checks
The evidence raised serious concern that blocked observation panels were not consistently challenged or cleared , and that visual welfare checks were therefore not always effective . The jury heard evidence that officers deliberately avoided opening blocked hatches to escape abuse from the prisoners then or later. In a prison environment where prisoners may be intoxicated, unconscious, self-harming, assaulted, or otherwise incapacitated behind a locked door, failure to maintain an unobstructed observation panel creates an obvious risk of late discovery and preventable death.
” 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Delays in supplying material information relevant to death investigations and future-death prevention
Wider context from the report “Concern 12: Failure of state agencies to supply all information in a timely fashion.
In this Inquest I was presented with material information at the eleventh hour . Aside from being discourteous to the family and the Court such tardy provision has potential to frustrate a full investigation into the death and allow elements of care which may impact on future deaths to pass unnoticed .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to implement sufficient and sustained remedial action on identified prison safety concerns
Wider context from the report “Concern 11: Repeated systemic concerns at HMP Woodhill
Material before the court from oversight and inspection bodies demonstrated that concerns about drugs, safety, violence, self-isolation, observation panel compliance, ACCT weaknesses and welfare monitoring at HMP Woodhill had been identified over time. I am concerned that repeated identification of these issues has not resulted in sufficient or sustained remedial action , creating an ongoing risk of further 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise IPP status as a material vulnerability requiring structured support and review
Wider context from the report “Concern 7: Particular vulnerability of prisoners serving IPP (Imprisonment for Public Protection) sentences
The evidence showed that prisoners serving IPP sentences may experience hopelessness, chronic frustration, deterioration in mental health and increased vulnerability to substance misuse and self-neglect . I am concerned that Mr Meikle's IPP status was not sufficiently recognised as a material risk factor requiring structured support, regular review and coordinated care .
” Open source report
11 Mar 2026 Peter Asher CAMPBELL · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 9 Failure to prevent drugs from entering the prison View source Failure to follow up when recovery-worker engagement is ineffective View source Failure to conduct recovery-worker interactions privately View source Failure of post-incident investigations to identify gaps in drug recovery care View source Failure to have meaningful discussions about prisoners’ drug use View source Harm-minimisation guidance failing to address risks to cellmates View source Failure to review medical records before recovery-worker interactions View source Failure of routine supervision or audit to identify gaps in drug recovery care View source Failure to ensure recovery-worker practice complies with training View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Peter Asher CAMPBELL · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Peter Asher Campbell collapsed in his prison cell at Pentonville after smoking a drug and died five days later. The principal concerns were the failure to prevent drugs entering the prison and shortcomings in the prison drug service’s response, including inadequate engagement, harm-minimisation advice, staff training, supervision and auditing.
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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent drugs from entering the prison
Wider context from the report “For HMPPS and Pentonville
In the narrative conclusion, the jury recorded a failure to prevent drugs from entering the prison .
Every witness at inquest who expressed a view gave evidence that drugs are rife within Pentonville, as they are across the prison estate. They enter attached to drones and in throw overs; via prison officers, visitors and prisoners; and, to a lesser extent these days, in the post. ████████, a drug many times more potent and dangerous than cannabis, ████████ It has infiltrated the prison population with enormous reach and with potentially devastating consequences for the prisoners themselves and for others - there is a risk of prisoners leaving prison in a worse state than when they went in, a state that may of course be reflected in violent reoffending.
Initially, I was not going to include that failure within my prevention of future deaths report, because the availability of drugs in prison seems such a huge and intractable problem. However, on reflection it seems to me that it would be complacent to view the size of the problem as prohibitive. Perhaps the size of the problem dictates only the size of the solution required.
At inquest, I heard about other aspects of the prison regime that were sub optimal, but it appeared that since Mr Campbell’s death, the staff at Pentonville had taken steps to address these.
However, the mass availability of drugs apparently persists without abatement . This is not in any way peculiar to Pentonville, but Pentonville is an exemplar.
” 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to follow up when recovery-worker engagement is ineffective
Wider context from the report “For Phoenix and PPG
Mr Campbell collapsed in prison on 18 September 2024 as he had done before following the use of ████████, and the prison and healthcare staff responded to this as an emergency code blue. The ambulance service was called and he was immediately conveyed to hospital where he was resuscitated.
The jury found a failure by the prison drug service to provide a meaningful interaction with Mr Campbell between the collapse on 18 September 2024 and the fatal collapse on 3 October 2024. This was partly because a visit was not arranged promptly, a systemic issue that since seems to have been addressed.
However, I also heard evidence that, when the Phoenix recovery worker did go to see Mr Campbell on 1 October 2024 in an attempt to promote harm minimisation:
• She did not read any part of his medical records before she saw him, and she did not know whether she was meant to do so. She was.
• She spoke to him through the hatch in the cell door, with his cellmate present. This was her normal practice, but she was not able to say why. It should not have been.
• She did not have any meaningful discussion with him about his drug use, either the use that led to his collapse on 18 September 2024 or his use generally. She should have.
• She gave him various pieces of harm minimisation guidance in keeping with her training, including the advice to avoid using drugs whilst alone. This advice was later confirmed as within policy by the Phoenix head of service. However, it does not seem to take account of the fact that smoking a drug in a small cell with a cellmate puts the cellmate at risk.
• Mr Campbell told her that he was not under the influence at the time. The recovery worker was not wholly convinced, but she did not return later that day or the following day to see if better engagement was possible . She should have.
• She did not know whether her interaction with Mr Campbell was in accordance with her training. I was told that it was not. She had not received further training or changed her practice since his death.
• The drug recovery worker was the last healthcare worker to see Mr Campbell before his fatal collapse from drugs and did so just two days before that occurred. However, the gaps in her care of Mr Campbell were not identified by the investigation following his death by Phoenix and PPG (or by the Prisons and Probation Ombudsman).
• She had not changed her practice since Mr Campbell’s death, but any gaps in her care of other prisoners had also not been identified in the following year and a half, either by routine supervision or by audit. I heard that audits are undertaken of the medical records only.
Therefore, the first time that Phoenix and PPG recognised a drug recovery worker’s failures to follow their procedures over at least a year and a half, was at the inquest.
” 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct recovery-worker interactions privately
Wider context from the report “For Phoenix and PPG
Mr Campbell collapsed in prison on 18 September 2024 as he had done before following the use of ████████, and the prison and healthcare staff responded to this as an emergency code blue. The ambulance service was called and he was immediately conveyed to hospital where he was resuscitated.
The jury found a failure by the prison drug service to provide a meaningful interaction with Mr Campbell between the collapse on 18 September 2024 and the fatal collapse on 3 October 2024. This was partly because a visit was not arranged promptly, a systemic issue that since seems to have been addressed.
However, I also heard evidence that, when the Phoenix recovery worker did go to see Mr Campbell on 1 October 2024 in an attempt to promote harm minimisation:
• She did not read any part of his medical records before she saw him, and she did not know whether she was meant to do so. She was.
• She spoke to him through the hatch in the cell door, with his cellmate present . This was her normal practice , but she was not able to say why. It should not have been.
• She did not have any meaningful discussion with him about his drug use, either the use that led to his collapse on 18 September 2024 or his use generally. She should have.
• She gave him various pieces of harm minimisation guidance in keeping with her training, including the advice to avoid using drugs whilst alone. This advice was later confirmed as within policy by the Phoenix head of service. However, it does not seem to take account of the fact that smoking a drug in a small cell with a cellmate puts the cellmate at risk.
• Mr Campbell told her that he was not under the influence at the time. The recovery worker was not wholly convinced, but she did not return later that day or the following day to see if better engagement was possible. She should have.
• She did not know whether her interaction with Mr Campbell was in accordance with her training. I was told that it was not. She had not received further training or changed her practice since his death.
• The drug recovery worker was the last healthcare worker to see Mr Campbell before his fatal collapse from drugs and did so just two days before that occurred. However, the gaps in her care of Mr Campbell were not identified by the investigation following his death by Phoenix and PPG (or by the Prisons and Probation Ombudsman).
• She had not changed her practice since Mr Campbell’s death, but any gaps in her care of other prisoners had also not been identified in the following year and a half, either by routine supervision or by audit. I heard that audits are undertaken of the medical records only.
Therefore, the first time that Phoenix and PPG recognised a drug recovery worker’s failures to follow their procedures over at least a year and a half, was at the inquest.
” 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure of post-incident investigations to identify gaps in drug recovery care
Wider context from the report “For Phoenix and PPG
Mr Campbell collapsed in prison on 18 September 2024 as he had done before following the use of ████████, and the prison and healthcare staff responded to this as an emergency code blue. The ambulance service was called and he was immediately conveyed to hospital where he was resuscitated.
The jury found a failure by the prison drug service to provide a meaningful interaction with Mr Campbell between the collapse on 18 September 2024 and the fatal collapse on 3 October 2024. This was partly because a visit was not arranged promptly, a systemic issue that since seems to have been addressed.
However, I also heard evidence that, when the Phoenix recovery worker did go to see Mr Campbell on 1 October 2024 in an attempt to promote harm minimisation:
• She did not read any part of his medical records before she saw him, and she did not know whether she was meant to do so. She was.
• She spoke to him through the hatch in the cell door, with his cellmate present. This was her normal practice, but she was not able to say why. It should not have been.
• She did not have any meaningful discussion with him about his drug use, either the use that led to his collapse on 18 September 2024 or his use generally. She should have.
• She gave him various pieces of harm minimisation guidance in keeping with her training, including the advice to avoid using drugs whilst alone. This advice was later confirmed as within policy by the Phoenix head of service. However, it does not seem to take account of the fact that smoking a drug in a small cell with a cellmate puts the cellmate at risk.
• Mr Campbell told her that he was not under the influence at the time. The recovery worker was not wholly convinced, but she did not return later that day or the following day to see if better engagement was possible. She should have.
• She did not know whether her interaction with Mr Campbell was in accordance with her training. I was told that it was not. She had not received further training or changed her practice since his death.
• The drug recovery worker was the last healthcare worker to see Mr Campbell before his fatal collapse from drugs and did so just two days before that occurred. However, the gaps in her care of Mr Campbell were not identified by the investigation following his death by Phoenix and PPG (or by the Prisons and Probation Ombudsman).
• She had not changed her practice since Mr Campbell’s death, but any gaps in her care of other prisoners had also not been identified in the following year and a half, either by routine supervision or by audit. I heard that audits are undertaken of the medical records only.
Therefore, the first time that Phoenix and PPG recognised a drug recovery worker’s failures to follow their procedures over at least a year and a half, was at the inquest.
” 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to have meaningful discussions about prisoners’ drug use
Wider context from the report “For Phoenix and PPG
Mr Campbell collapsed in prison on 18 September 2024 as he had done before following the use of ████████, and the prison and healthcare staff responded to this as an emergency code blue. The ambulance service was called and he was immediately conveyed to hospital where he was resuscitated.
The jury found a failure by the prison drug service to provide a meaningful interaction with Mr Campbell between the collapse on 18 September 2024 and the fatal collapse on 3 October 2024. This was partly because a visit was not arranged promptly, a systemic issue that since seems to have been addressed.
However, I also heard evidence that, when the Phoenix recovery worker did go to see Mr Campbell on 1 October 2024 in an attempt to promote harm minimisation:
• She did not read any part of his medical records before she saw him, and she did not know whether she was meant to do so. She was.
• She spoke to him through the hatch in the cell door, with his cellmate present. This was her normal practice, but she was not able to say why. It should not have been.
• She did not have any meaningful discussion with him about his drug use , either the use that led to his collapse on 18 September 2024 or his use generally. She should have.
• She gave him various pieces of harm minimisation guidance in keeping with her training, including the advice to avoid using drugs whilst alone. This advice was later confirmed as within policy by the Phoenix head of service. However, it does not seem to take account of the fact that smoking a drug in a small cell with a cellmate puts the cellmate at risk.
• Mr Campbell told her that he was not under the influence at the time. The recovery worker was not wholly convinced, but she did not return later that day or the following day to see if better engagement was possible. She should have.
• She did not know whether her interaction with Mr Campbell was in accordance with her training. I was told that it was not. She had not received further training or changed her practice since his death.
• The drug recovery worker was the last healthcare worker to see Mr Campbell before his fatal collapse from drugs and did so just two days before that occurred. However, the gaps in her care of Mr Campbell were not identified by the investigation following his death by Phoenix and PPG (or by the Prisons and Probation Ombudsman).
• She had not changed her practice since Mr Campbell’s death, but any gaps in her care of other prisoners had also not been identified in the following year and a half, either by routine supervision or by audit. I heard that audits are undertaken of the medical records only.
Therefore, the first time that Phoenix and PPG recognised a drug recovery worker’s failures to follow their procedures over at least a year and a half, was at the inquest.
” 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Harm-minimisation guidance failing to address risks to cellmates
Wider context from the report “For Phoenix and PPG
Mr Campbell collapsed in prison on 18 September 2024 as he had done before following the use of ████████, and the prison and healthcare staff responded to this as an emergency code blue. The ambulance service was called and he was immediately conveyed to hospital where he was resuscitated.
The jury found a failure by the prison drug service to provide a meaningful interaction with Mr Campbell between the collapse on 18 September 2024 and the fatal collapse on 3 October 2024. This was partly because a visit was not arranged promptly, a systemic issue that since seems to have been addressed.
However, I also heard evidence that, when the Phoenix recovery worker did go to see Mr Campbell on 1 October 2024 in an attempt to promote harm minimisation:
• She did not read any part of his medical records before she saw him, and she did not know whether she was meant to do so. She was.
• She spoke to him through the hatch in the cell door, with his cellmate present. This was her normal practice, but she was not able to say why. It should not have been.
• She did not have any meaningful discussion with him about his drug use, either the use that led to his collapse on 18 September 2024 or his use generally. She should have.
• She gave him various pieces of harm minimisation guidance in keeping with her training, including the advice to avoid using drugs whilst alone. This advice was later confirmed as within policy by the Phoenix head of service. However, it does not seem to take account of the fact that smoking a drug in a small cell with a cellmate puts the cellmate at risk .
• Mr Campbell told her that he was not under the influence at the time. The recovery worker was not wholly convinced, but she did not return later that day or the following day to see if better engagement was possible. She should have.
• She did not know whether her interaction with Mr Campbell was in accordance with her training. I was told that it was not. She had not received further training or changed her practice since his death.
• The drug recovery worker was the last healthcare worker to see Mr Campbell before his fatal collapse from drugs and did so just two days before that occurred. However, the gaps in her care of Mr Campbell were not identified by the investigation following his death by Phoenix and PPG (or by the Prisons and Probation Ombudsman).
• She had not changed her practice since Mr Campbell’s death, but any gaps in her care of other prisoners had also not been identified in the following year and a half, either by routine supervision or by audit. I heard that audits are undertaken of the medical records only.
Therefore, the first time that Phoenix and PPG recognised a drug recovery worker’s failures to follow their procedures over at least a year and a half, was at the inquest.
” 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to review medical records before recovery-worker interactions
Wider context from the report “For Phoenix and PPG
Mr Campbell collapsed in prison on 18 September 2024 as he had done before following the use of ████████, and the prison and healthcare staff responded to this as an emergency code blue. The ambulance service was called and he was immediately conveyed to hospital where he was resuscitated.
The jury found a failure by the prison drug service to provide a meaningful interaction with Mr Campbell between the collapse on 18 September 2024 and the fatal collapse on 3 October 2024. This was partly because a visit was not arranged promptly, a systemic issue that since seems to have been addressed.
However, I also heard evidence that, when the Phoenix recovery worker did go to see Mr Campbell on 1 October 2024 in an attempt to promote harm minimisation:
• She did not read any part of his medical records before she saw him , and she did not know whether she was meant to do so . She was.
• She spoke to him through the hatch in the cell door, with his cellmate present. This was her normal practice, but she was not able to say why. It should not have been.
• She did not have any meaningful discussion with him about his drug use, either the use that led to his collapse on 18 September 2024 or his use generally. She should have.
• She gave him various pieces of harm minimisation guidance in keeping with her training, including the advice to avoid using drugs whilst alone. This advice was later confirmed as within policy by the Phoenix head of service. However, it does not seem to take account of the fact that smoking a drug in a small cell with a cellmate puts the cellmate at risk.
• Mr Campbell told her that he was not under the influence at the time. The recovery worker was not wholly convinced, but she did not return later that day or the following day to see if better engagement was possible. She should have.
• She did not know whether her interaction with Mr Campbell was in accordance with her training. I was told that it was not. She had not received further training or changed her practice since his death.
• The drug recovery worker was the last healthcare worker to see Mr Campbell before his fatal collapse from drugs and did so just two days before that occurred. However, the gaps in her care of Mr Campbell were not identified by the investigation following his death by Phoenix and PPG (or by the Prisons and Probation Ombudsman).
• She had not changed her practice since Mr Campbell’s death, but any gaps in her care of other prisoners had also not been identified in the following year and a half, either by routine supervision or by audit. I heard that audits are undertaken of the medical records only.
Therefore, the first time that Phoenix and PPG recognised a drug recovery worker’s failures to follow their procedures over at least a year and a half, was at the inquest.
” 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure of routine supervision or audit to identify gaps in drug recovery care
Wider context from the report “For Phoenix and PPG
Mr Campbell collapsed in prison on 18 September 2024 as he had done before following the use of ████████, and the prison and healthcare staff responded to this as an emergency code blue. The ambulance service was called and he was immediately conveyed to hospital where he was resuscitated.
The jury found a failure by the prison drug service to provide a meaningful interaction with Mr Campbell between the collapse on 18 September 2024 and the fatal collapse on 3 October 2024. This was partly because a visit was not arranged promptly, a systemic issue that since seems to have been addressed.
However, I also heard evidence that, when the Phoenix recovery worker did go to see Mr Campbell on 1 October 2024 in an attempt to promote harm minimisation:
• She did not read any part of his medical records before she saw him, and she did not know whether she was meant to do so. She was.
• She spoke to him through the hatch in the cell door, with his cellmate present. This was her normal practice, but she was not able to say why. It should not have been.
• She did not have any meaningful discussion with him about his drug use, either the use that led to his collapse on 18 September 2024 or his use generally. She should have.
• She gave him various pieces of harm minimisation guidance in keeping with her training, including the advice to avoid using drugs whilst alone. This advice was later confirmed as within policy by the Phoenix head of service. However, it does not seem to take account of the fact that smoking a drug in a small cell with a cellmate puts the cellmate at risk.
• Mr Campbell told her that he was not under the influence at the time. The recovery worker was not wholly convinced, but she did not return later that day or the following day to see if better engagement was possible. She should have.
• She did not know whether her interaction with Mr Campbell was in accordance with her training. I was told that it was not. She had not received further training or changed her practice since his death.
• The drug recovery worker was the last healthcare worker to see Mr Campbell before his fatal collapse from drugs and did so just two days before that occurred. However, the gaps in her care of Mr Campbell were not identified by the investigation following his death by Phoenix and PPG (or by the Prisons and Probation Ombudsman).
• She had not changed her practice since Mr Campbell’s death, but any gaps in her care of other prisoners had also not been identified in the following year and a half, either by routine supervision or by audit . I heard that audits are undertaken of the medical records only .
Therefore, the first time that Phoenix and PPG recognised a drug recovery worker’s failures to follow their procedures over at least a year and a half, was at the inquest.
” 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure recovery-worker practice complies with training
Wider context from the report “For Phoenix and PPG
Mr Campbell collapsed in prison on 18 September 2024 as he had done before following the use of ████████, and the prison and healthcare staff responded to this as an emergency code blue. The ambulance service was called and he was immediately conveyed to hospital where he was resuscitated.
The jury found a failure by the prison drug service to provide a meaningful interaction with Mr Campbell between the collapse on 18 September 2024 and the fatal collapse on 3 October 2024. This was partly because a visit was not arranged promptly, a systemic issue that since seems to have been addressed.
However, I also heard evidence that, when the Phoenix recovery worker did go to see Mr Campbell on 1 October 2024 in an attempt to promote harm minimisation:
• She did not read any part of his medical records before she saw him, and she did not know whether she was meant to do so. She was.
• She spoke to him through the hatch in the cell door, with his cellmate present. This was her normal practice, but she was not able to say why. It should not have been.
• She did not have any meaningful discussion with him about his drug use, either the use that led to his collapse on 18 September 2024 or his use generally. She should have.
• She gave him various pieces of harm minimisation guidance in keeping with her training, including the advice to avoid using drugs whilst alone. This advice was later confirmed as within policy by the Phoenix head of service. However, it does not seem to take account of the fact that smoking a drug in a small cell with a cellmate puts the cellmate at risk.
• Mr Campbell told her that he was not under the influence at the time. The recovery worker was not wholly convinced, but she did not return later that day or the following day to see if better engagement was possible. She should have.
• She did not know whether her interaction with Mr Campbell was in accordance with her training . I was told that it was not . She had not received further training or changed her practice since his death .
• The drug recovery worker was the last healthcare worker to see Mr Campbell before his fatal collapse from drugs and did so just two days before that occurred. However, the gaps in her care of Mr Campbell were not identified by the investigation following his death by Phoenix and PPG (or by the Prisons and Probation Ombudsman).
• She had not changed her practice since Mr Campbell’s death, but any gaps in her care of other prisoners had also not been identified in the following year and a half, either by routine supervision or by audit. I heard that audits are undertaken of the medical records only.
Therefore, the first time that Phoenix and PPG recognised a drug recovery worker’s failures to follow their procedures over at least a year and a half, was at the inquest.
” 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 Provide trace detection equipment to public sector prisons to identify drugs on physical items.
Verbatim wording from the response “We utilise multiple countermeasures and initiatives to tackle the conveyance of drugs into prisons. For example, all adult male closed prisons are equipped with X-ray body scanners, which are used to detect and deter the internal concealment of illicit items by prisoners. Additionally, all public sector prisons have been provided with trace detection equipment, which is used to identify the presence of drugs on physical items. Furthermore, dedicated search teams are in place to find and remove illicit items. They are equipped with specialist” Source location Response from HMPPS
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 Provide airport-style enhanced gate security at 54 priority establishments to screen staff and visitors.
Verbatim wording from the response “HMPPS recognises that the vast majority of prison staff are hardworking and dedicated, but unfortunately a very small minority engage in corrupt activity, including the conveyance of drugs into prisons. To prevent and deter staff from engaging in this, we have a dedicated counter corruption unit, which provides training, support and guidance to staff, as well as pursuing those who engage in this kind of criminality. Outcomes for staff found guilty of corruption can range from dismissal through to criminal prosecution. To support this work, 54 priority establishments have airport-style enhanced gate security, including archway metal detectors, handheld wands, and X-ray baggage scanners, to screen staff and visitors.” Source location Response from HMPPS
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 Maintain dedicated search teams equipped with specialist tools to detect and retrieve illicit items, including mobile phones.
Verbatim wording from the response “We utilise multiple countermeasures and initiatives to tackle the conveyance of drugs into prisons. For example, all adult male closed prisons are equipped with X-ray body scanners, which are used to detect and deter the internal concealment of illicit items by prisoners. Additionally, all public sector prisons have been provided with trace detection equipment, which is used to identify the presence of drugs on physical items. Furthermore, dedicated search teams are in place to find and remove illicit items. They are equipped with specialist” Source location Response from HMPPS
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 Equip adult male closed prisons with X-ray body scanners to detect and deter internally concealed illicit items.
Verbatim wording from the response “We utilise multiple countermeasures and initiatives to tackle the conveyance of drugs into prisons. For example, all adult male closed prisons are equipped with X-ray body scanners, which are used to detect and deter the internal concealment of illicit items by prisoners. Additionally, all public sector prisons have been provided with trace detection equipment, which is used to identify the presence of drugs on physical items. Furthermore, dedicated search teams are in place to find and remove illicit items. They are equipped with specialist” Source location Response from HMPPS
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 Operate a dedicated counter-corruption unit providing staff training, support and guidance while pursuing corruption cases.
Verbatim wording from the response “HMPPS recognises that the vast majority of prison staff are hardworking and dedicated, but unfortunately a very small minority engage in corrupt activity, including the conveyance of drugs into prisons. To prevent and deter staff from engaging in this, we have a dedicated counter corruption unit, which provides training, support and guidance to staff, as well as pursuing those who engage in this kind of criminality. Outcomes for staff found guilty of corruption can range from dismissal through to criminal prosecution. To support this work, 54 priority establishments have airport-style enhanced gate security, including archway metal detectors, handheld wands, and X-ray baggage scanners, to screen staff and visitors.” Source location Response from HMPPS
Open published response
3 Mar 2026 Mujahid Adam · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 4 Failure to record 15-minute observations contemporaneously and accurately View source Lack of a clear definition and procedure for 15-minute observations View source Failure to maintain special cells in a condition that prevents access to ligature-making material View source Failure of daily accommodation and fabric checks to identify disrepair in special cells View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mujahid Adam · 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
Mujahid Adam died by suicide after being found hanging in his prison cell on 15 March 2025; he was declared dead on 21 March 2025 at University College Hospital. The concerns included inadequate and non-contemporaneous recording of 15-minute observations, no clear definition of what constituted an observation, delays in calling Code Blue and cutting him down, and disrepair in the cell that allowed access to ligature material.
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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to record 15-minute observations contemporaneously and accurately
Wider context from the report “(a) The recording of observations of 15-minute checks is not contemporaneous and is prone to inaccuracy . It relies on a prison officer walking from the cell to the wing office to record observations, every 15 minutes, which may not be realistic if a prisoner has other duties to perform ;
” 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear definition and procedure for 15-minute observations
Wider context from the report “(b) There is no clear definition of what constitutes an “observation” and how this should be done by staff at the prison when someone is on 15-minute observations ;
” 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain special cells in a condition that prevents access to ligature-making material
Wider context from the report “(c) The cell occupied by Mr Adam is one of a handful of special cells in the prison which are used for vulnerable prisoners on constant watch or on 15-minute observation. It was in a state of disrepair and gave access to the hidden material from which a ligature could be made . Despite daily AFCs, that disrepair was not noted although this was a special 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure of daily accommodation and fabric checks to identify disrepair in special cells
Wider context from the report “(c) The cell occupied by Mr Adam is one of a handful of special cells in the prison which are used for vulnerable prisoners on constant watch or on 15-minute observation. It was in a state of disrepair and gave access to the hidden material from which a ligature could be made. Despite daily AFCs, that disrepair was not noted although this was a special cell .
” 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 Submit a bid to upgrade constant supervision cells to ligature-resistant specifications and address disrepair.
Verbatim wording from the response “In response to concerns about the condition of constant supervision cells at HMP Pentonville, I can confirm that a bid has been submitted to upgrade these cells to ligature resistant specifications. This work will address any disrepair and reduce opportunities for prisoners to use the fabric of the accommodation to ligature. In addition, staff at HMP Pentonville have been reminded of their responsibility to complete daily accommodation fabric checks. These are physical checks of all prisoner living areas, including cells, to ensure that the area is clean, decent and fit for purpose. They are also valuable opportunities for staff to identify anything that raises suspicion, including items that can be used to ligature.” Source location 2026-0125 - Response from HMPPS
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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 Re-introduce the Pentonville Speed School to deliver refresher training on observations and suicide and self-harm prevention.
Verbatim wording from the response “To ensure staff’s continuous understanding, HMP Pentonville is re-introducing the “Pentonville Speed School”, which is an initiative that provides staff with bitesize training sessions in key subject areas. The local safety team will work in conjunction with the school” Source location 2026-0125 - Response from HMPPS
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 Remind Pentonville staff to complete daily accommodation fabric checks, including checks for items that could be used to ligature.
Verbatim wording from the response “In response to concerns about the condition of constant supervision cells at HMP Pentonville, I can confirm that a bid has been submitted to upgrade these cells to ligature resistant specifications. This work will address any disrepair and reduce opportunities for prisoners to use the fabric of the accommodation to ligature. In addition, staff at HMP Pentonville have been reminded of their responsibility to complete daily accommodation fabric checks. These are physical checks of all prisoner living areas, including cells, to ensure that the area is clean, decent and fit for purpose. They are also valuable opportunities for staff to identify anything that raises suspicion, including items that can be used to ligature.” Source location 2026-0125 - Response from HMPPS
Open published response
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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 Contemporaneous ACCT observation recording is not feasible because staff cannot carry the document confidentially or without restricting their response to incidents.
Verbatim wording from the response “Prisoners may require more frequent observations depending on their level of risk, which can be labour intensive for staff. As you have noted, staff do not carry the ACCT document with them when conducting an observation. This is to mitigate the risk of other prisoners becoming privy to sensitive information about the individual being supported. It is also impractical for a member of staff to carry a large document whilst conducting their duties as it would restrict their ability to respond effectively to any emerging incidents. Due to this, the documenting of observations cannot be contemporaneous and must be completed after the event. Staff are required to complete these observations and record them either immediately or as soon as practicable afterwards, alongside their other duties.” Source location 2026-0125 - Response from HMPPS
Open published response
9 Feb 2026 Gareth Chumber-Kelly · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 4 Inefficiency and slowness of the prison reception process View source Failure to provide suicide and self-harm risk management training to prison officers View source Failure to provide regular mandatory basic life support training to prison officers View source Failure to retain documentation accompanying prisoners during reception View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Gareth Chumber-Kelly · 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
Gareth Chumber-Kelly died after hanging himself while in custody at HMP Pentonville on 17 July 2023. The report identified concerns about lost or incomplete transfer documentation, inadequate recognition and management of suicide and self-harm risks, insufficient staff training, failures to provide basic life support, and inadequate staffing and support during crucial periods.
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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Inefficiency and slowness of the prison reception process
Wider context from the report “(1) The court heard evidence from prison staff that the reception process at HMP Pentonville was inefficient and slow and that paperwork would be sometimes be lost. This creates a risk to the safety and well-being of prisoners as the documentation accompanying the prisoner as they are conveyed to prison may contain (as was the case with Mr Chumber-Kelly) very important information about the prisoners which is relevant to ensuring all appropriate steps and measures are put in place to protect them. The Governor at HMP Pentonville told the court that no steps have been taken to address this recurrent problem , and the risk of important documentation being lost, and there has been no dialogue with Serco to address this issue.
” 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to provide suicide and self-harm risk management training to prison officers
Wider context from the report “(2) The court heard evidence that 2 prisoners had died by ligature suspension (on 17.6.2021 and 1.3.22) prior to Mr Chumber-Kelly’s death, and that since then a further 5 prisoners have died by ligature suspension (one of which was Mr Chumber-Kelly). The Governor of HMP Pentonville told the court that Suicide and Self harm training for prison staff had been suspended during Covid and had never been re-started notwithstanding that 38% of prisoners arriving at HMP Pentonville said they felt suicidal and notwithstanding that 7 prisoners have died by ligature suspension since June 2021. The failure to train prison officers in the risks and management of suicide and self-harm creates a risk of 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to provide regular mandatory basic life support training to prison officers
Wider context from the report “(3) The court heard evidence that the first two officers on the scene failed to provide any form of basic life support despite having received training on how to do so. Both officers described how they panicked and did not know what to do. The court heard evidence from a consultant paramedic from the London Ambulance service with extensive experience in resuscitation who explained that for every minute without CPR there is a 10-22% drop in survival rates. It is critically important that the first person on the scene in such emergency situations (who will almost always be the prison officers) are properly and regularly trained in basic life support so that they are able to render such aid immediately on arrival. The Governor of the prison told the court that no refresher CPR training had been provided to prison staff since 2023 notwithstanding the 5 deaths of prisoners by ligature suspension that have occurred since. This is deeply concerning given that this very same issue was raised in a Prevention of Future Deaths Report by Mary Hassell, HM Senior Coroner of Inner North London on 18th September 2023 relating to the death of Amarjit Singh and yet in the 2 years since that PFD was issued there is still no mandatory basic life support training for prison officers .
The failure of the prison to provide regular, mandatory basic life support to all prison officer creates a risk of 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to retain documentation accompanying prisoners during reception
Wider context from the report “(1) The court heard evidence from prison staff that the reception process at HMP Pentonville was inefficient and slow and that paperwork would be sometimes be lost . This creates a risk to the safety and well-being of prisoners as the documentation accompanying the prisoner as they are conveyed to prison may contain (as was the case with Mr Chumber-Kelly) very important information about the prisoners which is relevant to ensuring all appropriate steps and measures are put in place to protect them. The Governor at HMP Pentonville told the court that no steps have been taken to address this recurrent problem, and the risk of important documentation being lost , and there has been no dialogue with Serco to address this issue.
” 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 Reintroduce the Pentonville Speed School and deliver self-harm and suicide-prevention training to officers.
Verbatim wording from the response “With regards to your training concerns, HMP Pentonville is re-introducing the “Pentonville Speed School”, which is an initiative that provides staff with bitesize training sessions in key subject areas. The local safety team will work in conjunction with the school to deliver training on self-harm and suicide prevention to officers. Additionally, all band 4 staff at HMP Pentonville have now received the Assessment, Care and Teamwork (ACCT) case review training, which equips them with the skills to be able to provide prisoners at risk of suicide with holistic and person-centred support in their role as ACCT case coordinators.” Source location Response from HMPPS
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 Provide ACCT case-review training to all band 4 staff.
Verbatim wording from the response “With regards to your training concerns, HMP Pentonville is re-introducing the “Pentonville Speed School”, which is an initiative that provides staff with bitesize training sessions in key subject areas. The local safety team will work in conjunction with the school to deliver training on self-harm and suicide prevention to officers. Additionally, all band 4 staff at HMP Pentonville have now received the Assessment, Care and Teamwork (ACCT) case review training, which equips them with the skills to be able to provide prisoners at risk of suicide with holistic and person-centred support in their role as ACCT case coordinators.” Source location Response from HMPPS
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 Review reception procedures and implement necessary improvements identified through the review.
Verbatim wording from the response “To strengthen oversight of early days in custody, the prison has appointed a Head of Early Days with specific responsibility for the reception function. As part of their remit, they are leading a comprehensive review of reception procedures to identify any aspects, such as documentation handling, that may require improvement and to implement any necessary changes.” Source location Response from HMPPS
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 Deliver basic life-saving and CPR refresher sessions to staff through qualified Physical Education Instructors.
Verbatim wording from the response “The Pentonville Speed School will support this work by utilising Physical Education Instructors, who are qualified first aid trainers, to deliver basic life-saving skills to staff, including training in CPR. These short, practical sessions will ensure that staff receive essential refresher training and thereby increasing their confidence when responding to medical emergencies. In addition, HMP Pentonville is promoting the first aid at work course and encouraging wider staff participation to ensure that key areas of the establishment maintain sufficient qualified first aiders.” Source location Response from HMPPS
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 regular early-days exercises to test reception and induction processes and identify further improvements.
Verbatim wording from the response “In addition, the group safety team conducts regular early days exercises, which replicate a prisoner’s arrival and induction experience. These assurance activities are used to test the effectiveness and consistency of the reception process in practice, and to identify areas where further improvements may be required. These combined measures are intended to strengthen risk information management, enhance operational oversight, and support continuous improvement of the safety and experience of those entering HMP Pentonville.” Source location Response from HMPPS
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 Provide digital Person Escort Records for PECS movements and enable authorised professionals to update them before arrival.
Verbatim wording from the response “Following the implementation of the Book a Secure Move (BaSM) system, the PECS Contract Management Team has ensured that digital Person Escort Records (DPERs) are available for all prisoners moved by PECS suppliers between courts, prisons and police stations. Recent system enhancements enable authorised professionals, including medical practitioners and L&D services, to update a prisoner’s DPER directly following assessment. These updates are visible to receiving establishments once the prisoner is booked in from court or prison, prior to arrival.” Source location Response from HMPPS
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 Develop and provide first-aid instructional materials through staff e-learning platforms.
Verbatim wording from the response “More widely, HMPPS develops staff capability through refresher courses and communication packages. Materials, including instructional videos, have been developed and are available to staff through E-learning platforms to update and maintain their first aid knowledge and skills. These provide practical guidance on what to do in several potential scenarios that staff may encounter in the course of their duties.” Source location Response from HMPPS
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 Promote the first-aid-at-work course and encourage wider staff participation to maintain sufficient qualified first aiders.
Verbatim wording from the response “The Pentonville Speed School will support this work by utilising Physical Education Instructors, who are qualified first aid trainers, to deliver basic life-saving skills to staff, including training in CPR. These short, practical sessions will ensure that staff receive essential refresher training and thereby increasing their confidence when responding to medical emergencies. In addition, HMP Pentonville is promoting the first aid at work course and encouraging wider staff participation to ensure that key areas of the establishment maintain sufficient qualified first aiders.” Source location Response from HMPPS
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 Use a digital induction passport to consolidate, store and share key risk information during reception.
Verbatim wording from the response “HMP Pentonville has introduced a digital induction passport to consolidate key risk information from paper records into a secure electronic format. This enables relevant information to be accurately captured, stored, and shared between departments, reducing the likelihood of omissions or data loss during the induction process.” Source location Response from HMPPS
Open published response
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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 PECS suppliers are not contractually responsible for physically transferring hard-copy medical or risk documentation between courts and prisons.
Verbatim wording from the response “The Prison Escort and Custody Services (PECS) team within HMPPS recognises the importance of the timely and accurate transfer of risk and safeguarding information and treats this as a matter of serious operational priority. Responsibility for the creation, maintenance and clinical transfer of healthcare and associated risk information rests with qualified medical professionals. In this case, Liaison and Diversion (L&D) services are responsible for ensuring that relevant records are effectively shared with receiving prison healthcare teams. The PECS contracts do not place responsibility on PECS suppliers for the physical transfer of hard-copy medical or risk documentation between courts and prisons.” Source location Response from HMPPS
Open published response
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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 Qualified medical professionals and Liaison and Diversion services are responsible for creating, maintaining and transferring healthcare and associated risk information.
Verbatim wording from the response “The Prison Escort and Custody Services (PECS) team within HMPPS recognises the importance of the timely and accurate transfer of risk and safeguarding information and treats this as a matter of serious operational priority. Responsibility for the creation, maintenance and clinical transfer of healthcare and associated risk information rests with qualified medical professionals. In this case, Liaison and Diversion (L&D) services are responsible for ensuring that relevant records are effectively shared with receiving prison healthcare teams. The PECS contracts do not place responsibility on PECS suppliers for the physical transfer of hard-copy medical or risk documentation between courts and prisons.” Source location Response from HMPPS
Open published response
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
Each statement is shown once, even when linked to more than one concern.
×
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 HM Prison and Probation Service; 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 HM Prison and Probation Service; 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 HM Prison and Probation Service; 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 HM Prison and Probation Service; 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 HM Prison and Probation Service; 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 HM Prison and Probation Service; 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 HM Prison and Probation Service; 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 HM Prison and Probation Service; 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 HM Prison and Probation Service; 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 HM Prison and Probation Service; 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 HM Prison and Probation Service; 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 HM Prison and Probation Service; 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 HM Prison and Probation Service; 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 HM Prison and Probation Service; 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
×
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 Deliver interim risk-identification upskilling sessions across the reception estate.
Verbatim wording from the response “Safety Group has developed interim upskilling sessions focused specifically on risk identification at the point of the prisoner’s arrival in custody. These sessions will be delivered across the reception estate by the National Safety Group and Group Safety Leads, with completion anticipated by June 2026, subject to confirmation.” Source location Response from HM Prison & Probation Service
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 Review Reception Officer training to strengthen early-custody risk-identification and support for vulnerable individuals.
Verbatim wording from the response “Further, a comprehensive review of the Reception Officer training has commenced, and the National Safety Group have already proposed enhancements that will strengthen risk-identification skills and improve support for individuals who may be particularly vulnerable during their early days in custody. The revised training will be completed once PLDD capacity allows.” Source location Response from HM Prison & Probation Service
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 Review the risks, triggers and protective factors module in collaboration with Prison Learning Design and Delivery.
Verbatim wording from the response “Recognition of the risks and triggers that may increase a prisoner’s risk of suicide and self-harm is a vital skill for prison officers. The Safety Support Skills training within Foundation Training, formerly Prison Officer Entry Level Training (POELT), comprises approximately 18 hours of the overall curriculum and of this, the dedicated session on identifying and managing risk factors and triggers accounts for between 45 minutes to one hour of the training. The risks, triggers and protective factors module is currently under national review in collaboration with Prison Learning Design and Delivery (PLDD). While this work progresses, the National” Source location Response from HM Prison & Probation Service
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 Complete the revised Reception Officer training once Prison Learning Design and Delivery capacity allows.
Verbatim wording from the response “Further, a comprehensive review of the Reception Officer training has commenced, and the National Safety Group have already proposed enhancements that will strengthen risk-identification skills and improve support for individuals who may be particularly vulnerable during their early days in custody. The revised training will be completed once PLDD capacity allows.” Source location Response from HM Prison & Probation Service
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 Submit a local business case to upgrade HMP Chelmsford Victorian-style windows to anti-ligature designs.
Verbatim wording from the response “Nationally, we recognise that older cells can contain multiple potential ligature fixtures—including plumbing, furniture, and electrical fittings. HMP Chelmsford have submitted a local business case seeking to upgrade Victorian-style windows to anti-ligature designs.” Source location Response from HM Prison & Probation Service
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 Complete conversion of 50 cells across 13 locations to a ligature-resistant standard.
Verbatim wording from the response “The long-term solution is the redevelopment of cells to a fully ligature-resistant (LR) standard. Although newer prisons and refurbished wings are built to this specification, much of the estate predates the LR standard and does not currently include extensive LR provision. We are concluding a project to convert 50 cells across 13 locations, prioritised according to assessed levels of risk. This includes HMP Chelmsford, where four LR cells were completed in 2025. While LR cells are valuable, they are not always appropriate for individuals requiring constant supervision. In such cases, purpose-built constant-supervision cells offer greater visibility for staff, are the safer alternative, and several are already available at HMP Chelmsford. Subject to funding, we aim to increase the provision of LR cells nationally in the coming financial year.” Source location Response from HM Prison & Probation Service
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 National provision of ligature-resistant cells will increase subject to funding.
Verbatim wording from the response “The long-term solution is the redevelopment of cells to a fully ligature-resistant (LR) standard. Although newer prisons and refurbished wings are built to this specification, much of the estate predates the LR standard and does not currently include extensive LR provision. We are concluding a project to convert 50 cells across 13 locations, prioritised according to assessed levels of risk. This includes HMP Chelmsford, where four LR cells were completed in 2025. While LR cells are valuable, they are not always appropriate for individuals requiring constant supervision. In such cases, purpose-built constant-supervision cells offer greater visibility for staff, are the safer alternative, and several are already available at HMP Chelmsford. Subject to funding, we aim to increase the provision of LR cells nationally in the coming financial year.” Source location Response from HM Prison & Probation Service
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 Revised Reception Officer training will be completed once Prison Learning Design and Delivery capacity allows.
Verbatim wording from the response “Further, a comprehensive review of the Reception Officer training has commenced, and the National Safety Group have already proposed enhancements that will strengthen risk-identification skills and improve support for individuals who may be particularly vulnerable during their early days in custody. The revised training will be completed once PLDD capacity allows.” Source location Response from HM Prison & Probation Service
Open published response
10 Dec 2025 Mesut Olgun · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 1 Unavailability of Safer Cells outside the Segregation Unit for vulnerable prisoners View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mesut Olgun · 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
Mesut Olgun sustained significant injuries while being arrested and was later seriously injured in his cell at HMP Hewell on 8 June 2018; he died from those injuries at Alexandra Hospital, Redditch, on 14 June 2018. The inquest concluded that he died as a result of suicide. Concerns included the lack of “Safer Cells” outside the Segregation Unit, failures to carry out most required ACCT observations, and failure to call a Code Blue emergency at the earliest opportunity; the inquest found that the latter two failures possibly caused or contributed 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Unavailability of Safer Cells outside the Segregation Unit for vulnerable prisoners
Wider context from the report “In his evidence to the inquest, the current Head of Safety at HMP Hewell confirmed that the prison had two “Safer Cells” ( intended to reduce the risk ████████ ), but that these were both located within the prison’s Segregation Unit. He agreed that it would not be appropriate for a new prisoner like Mr. Olgun, who had been identified as a high risk of self-harm and for whom an ACCT document had been opened, to be located on the Segregation Unit on his first night in prison. There are therefore no “Safer Cells” located within the main body of the prison. The cost of converting a cell into a “Safer Cell” is said to be in the region of £70,000, for which funding would have to be sought from H.M. Prison and Probation Service, but HMP Hewell has not made any bid for such funding since Mr. Olgun’s death 7½ years ago.
The Head of Safety at the prison also confirmed in evidence that the two available “Safer Cells” have been used to house prisoners within the Segregation Unit who are thought to be at an increased risk of suicide or self-harm. This would suggest that the prison accepts in principle that such cells have a meaningful role to play in reducing such risk.
I am concerned that as long as “Safer Cells” are not made available away from the Segregation Unit at HMP Hewell, an important measure for reducing the risk of suicide or self-harm is being withheld from vulnerable prisoners at that prison.
” 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 Convert 50 cells to ligature-resistant standard across 13 establishments.
Verbatim wording from the response “At present, HMPPS is nearing completion of a project to convert fifty cells across thirteen establishments, which were selected on the assessed levels of risk at the time. We are hopeful that further installations will be possible in 2026/27, again prioritising locations with the highest assessed level of risk.” Source location Response from HM Prison & Probation Service
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 Further expansion of ligature-resistant cell provision is conditional on available resources.
Verbatim wording from the response “It is important to emphasise that an LR cell on its own cannot eliminate risk. The term “ligature-resistant” replaced “safer cell” to reflect the reality that prisoners may still find other means to self-harm. Staff guidance makes clear that LR cells are a valuable measure, but they must be used alongside other forms of support. Where LR cells are unavailable, or where moving a prisoner could increase risk, these alternative measures remain essential. Nonetheless, HMPPS’ ongoing ambition is to strengthen this approach further by expanding LR cell provision wherever resources permit.” Source location Response from HM Prison & Probation Service
Open published response
8 Dec 2025 OLIVER MULANGALA · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 5 Use of drones to deliver drugs and other contraband into prison View source Easy availability of new psychoactive substances in prison View source Easy availability of mobile phones in prison View source Failure to hold statistics on drug-related deaths in prisons View source Failure to protect vulnerable prisoners from forced testing of illegal drugs View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
OLIVER MULANGALA · 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
Oliver Mulangala was in custody at HMP High Down, had epilepsy and a history of serious seizures, and was found dead in his cell on 13 July 2024 after suffering a drug-induced seizure. The report identifies concerns about the easy availability and use of illicit new psychoactive substances in HMP High Down, including their contribution to drug-related deaths, coercion and risks to prisoners. It also raises concerns about the availability of mobile phones and the use of drones to facilitate the delivery of drugs and other contraband into prisons.
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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Use of drones to deliver drugs and other contraband into prison
Wider context from the report “It is of grave concern that:
(1) New psychoactive substances, especially ███, are easily available in HM Prison High Down, as in many other prisons in England & Wales
a. New psychoactive substances are dangerous illegal drugs of abuse (there is no clinical or medical use for them) and they are responsible for the death of a prisoner in England and Wales about every 5 days
b. Prisoners are coming into prison without a drug habit and develop a drug habit in prison due to the ease of their availability
c. Vulnerable prisoners are being forced to test new batches of illegal drugs coming into the prison
(2) Mobile phones are easily available in HM Prison High Down, as in many other prisons in England & Wales
a. The access to mobile phones facilitates prisoners’ conduct and finance of drug dealing, including the arranging for the delivery of drugs by drones to precise locations at specified times
b. The access to mobile phones allows sharing information (including photographs and videos) across not only High Down prison, but across other prisons in England & Wales, presenting safety and security risks
c. The access to mobile phones facilitates the highly lucrative, damaging and dangerous activities of the organised criminal gangs working in HM High Down, and other prisons in England & Wales
(3) The use of ███ in HMP High Down, as in other prisons in England & Wales, presents a serious risk to prison safety and security
a. ███ facilitate the delivery of drugs into prison to precise locations at specified times
b. ███ can be used to bring in other contraband including weapons and even firearms
c. The increasing sophistication of ███ (and their increasing payload) increases the risks and dangers to life
(4) The Ministry of Justice advised the court that it does not hold statistics on drug-related deaths in prisons in England & Wales. Basic risk management requires risks to be quantified and assessed in order that they can be addressed. You cannot properly manage that which you do not measure.
” 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Easy availability of new psychoactive substances in prison
Wider context from the report “It is of grave concern that:
(1) New psychoactive substances, especially ███, are easily available in HM Prison High Down, as in many other prisons in England & Wales
a. New psychoactive substances are dangerous illegal drugs of abuse (there is no clinical or medical use for them) and they are responsible for the death of a prisoner in England and Wales about every 5 days
b. Prisoners are coming into prison without a drug habit and develop a drug habit in prison due to the ease of their availability
c. Vulnerable prisoners are being forced to test new batches of illegal drugs coming into the prison
(2) Mobile phones are easily available in HM Prison High Down, as in many other prisons in England & Wales
a. The access to mobile phones facilitates prisoners’ conduct and finance of drug dealing, including the arranging for the delivery of drugs by drones to precise locations at specified times
b. The access to mobile phones allows sharing information (including photographs and videos) across not only High Down prison, but across other prisons in England & Wales, presenting safety and security risks
c. The access to mobile phones facilitates the highly lucrative, damaging and dangerous activities of the organised criminal gangs working in HM High Down, and other prisons in England & Wales
(3) The use of ███ in HMP High Down, as in other prisons in England & Wales, presents a serious risk to prison safety and security
a. ███ facilitate the delivery of drugs into prison to precise locations at specified times
b. ███ can be used to bring in other contraband including weapons and even firearms
c. The increasing sophistication of ███ (and their increasing payload) increases the risks and dangers to life
(4) The Ministry of Justice advised the court that it does not hold statistics on drug-related deaths in prisons in England & Wales. Basic risk management requires risks to be quantified and assessed in order that they can be addressed. You cannot properly manage that which you do not measure.
” 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Easy availability of mobile phones in prison
Wider context from the report “It is of grave concern that:
(1) New psychoactive substances, especially ███, are easily available in HM Prison High Down, as in many other prisons in England & Wales
a. New psychoactive substances are dangerous illegal drugs of abuse (there is no clinical or medical use for them) and they are responsible for the death of a prisoner in England and Wales about every 5 days
b. Prisoners are coming into prison without a drug habit and develop a drug habit in prison due to the ease of their availability
c. Vulnerable prisoners are being forced to test new batches of illegal drugs coming into the prison
(2) Mobile phones are easily available in HM Prison High Down, as in many other prisons in England & Wales
a. The access to mobile phones facilitates prisoners’ conduct and finance of drug dealing, including the arranging for the delivery of drugs by drones to precise locations at specified times
b. The access to mobile phones allows sharing information (including photographs and videos) across not only High Down prison, but across other prisons in England & Wales, presenting safety and security risks
c. The access to mobile phones facilitates the highly lucrative, damaging and dangerous activities of the organised criminal gangs working in HM High Down, and other prisons in England & Wales
(3) The use of ███ in HMP High Down, as in other prisons in England & Wales, presents a serious risk to prison safety and security
a. ███ facilitate the delivery of drugs into prison to precise locations at specified times
b. ███ can be used to bring in other contraband including weapons and even firearms
c. The increasing sophistication of ███ (and their increasing payload) increases the risks and dangers to life
(4) The Ministry of Justice advised the court that it does not hold statistics on drug-related deaths in prisons in England & Wales. Basic risk management requires risks to be quantified and assessed in order that they can be addressed. You cannot properly manage that which you do not measure.
” 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to hold statistics on drug-related deaths in prisons
Wider context from the report “It is of grave concern that:
(1) New psychoactive substances, especially ███, are easily available in HM Prison High Down, as in many other prisons in England & Wales
a. New psychoactive substances are dangerous illegal drugs of abuse (there is no clinical or medical use for them) and they are responsible for the death of a prisoner in England and Wales about every 5 days
b. Prisoners are coming into prison without a drug habit and develop a drug habit in prison due to the ease of their availability
c. Vulnerable prisoners are being forced to test new batches of illegal drugs coming into the prison
(2) Mobile phones are easily available in HM Prison High Down, as in many other prisons in England & Wales
a. The access to mobile phones facilitates prisoners’ conduct and finance of drug dealing, including the arranging for the delivery of drugs by drones to precise locations at specified times
b. The access to mobile phones allows sharing information (including photographs and videos) across not only High Down prison, but across other prisons in England & Wales, presenting safety and security risks
c. The access to mobile phones facilitates the highly lucrative, damaging and dangerous activities of the organised criminal gangs working in HM High Down, and other prisons in England & Wales
(3) The use of ███ in HMP High Down, as in other prisons in England & Wales, presents a serious risk to prison safety and security
a. ███ facilitate the delivery of drugs into prison to precise locations at specified times
b. ███ can be used to bring in other contraband including weapons and even firearms
c. The increasing sophistication of ███ (and their increasing payload) increases the risks and dangers to life
(4) The Ministry of Justice advised the court that it does not hold statistics on drug-related deaths in prisons in England & Wales . Basic risk management requires risks to be quantified and assessed in order that they can be addressed. You cannot properly manage that which you do not measure.
” 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to protect vulnerable prisoners from forced testing of illegal drugs
Wider context from the report “It is of grave concern that:
(1) New psychoactive substances, especially ███, are easily available in HM Prison High Down, as in many other prisons in England & Wales
a. New psychoactive substances are dangerous illegal drugs of abuse (there is no clinical or medical use for them) and they are responsible for the death of a prisoner in England and Wales about every 5 days
b. Prisoners are coming into prison without a drug habit and develop a drug habit in prison due to the ease of their availability
c. Vulnerable prisoners are being forced to test new batches of illegal drugs coming into the prison
(2) Mobile phones are easily available in HM Prison High Down, as in many other prisons in England & Wales
a. The access to mobile phones facilitates prisoners’ conduct and finance of drug dealing, including the arranging for the delivery of drugs by drones to precise locations at specified times
b. The access to mobile phones allows sharing information (including photographs and videos) across not only High Down prison, but across other prisons in England & Wales, presenting safety and security risks
c. The access to mobile phones facilitates the highly lucrative, damaging and dangerous activities of the organised criminal gangs working in HM High Down, and other prisons in England & Wales
(3) The use of ███ in HMP High Down, as in other prisons in England & Wales, presents a serious risk to prison safety and security
a. ███ facilitate the delivery of drugs into prison to precise locations at specified times
b. ███ can be used to bring in other contraband including weapons and even firearms
c. The increasing sophistication of ███ (and their increasing payload) increases the risks and dangers to life
(4) The Ministry of Justice advised the court that it does not hold statistics on drug-related deaths in prisons in England & Wales. Basic risk management requires risks to be quantified and assessed in order that they can be addressed. You cannot properly manage that which you do not measure.
” 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 Examine all drug-related deaths through the early learning review process and use findings and recommendations to address safety concerns.
Verbatim wording from the response “However, we do monitor such deaths closely and ensure that lessons are learned from them. All drug-related deaths are examined through our early learning review process, in which cases are reviewed by the group safety lead and the resulting report considered by the Governor, the Prison Group Director and the national Safety Group and Drug and Alcohol Group. And we study the outcomes of Prisons and Probation Ombudsman’s reports and ingests in these cases very carefully and take action to address any recommendations and matters of concern that are reported.” Source location Response from HM Prison and Probation Service
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 Deliver staff upskilling to improve responses to drone activity affecting prisons.
Verbatim wording from the response “We also work closely with law enforcement organisations to tackle prisons being targeted by drones. The Director General of the National Crime Agency has directed police chiefs to work with HMPPS to jointly tackle the threat of drones. For example, there are 400m restricted fly zones around all closed prisons and Young Offender Institutions. These restrictions make all unauthorised drone incursions a crime and support police and prison staff to disrupt illegal drone use. Additionally, we have developed comprehensive guidance and are delivering upskilling to staff to improve the response to drone activity impacting our prisons. HMPPS also conducts vulnerability assessments across the estate to understand the risk so that we can develop and implement plans to mitigate the threat.” Source location Response from HM Prison and Probation Service
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 Provide trace-detection equipment to all public sector prisons to identify drugs on physical items.
Verbatim wording from the response “illicit items by prisoners. Additionally, all public sector prisons have been provided with trace detection equipment, which is used to identify the presence of drugs on physical items. Furthermore, 54 priority establishments have airport-style enhanced gate security to screen staff and visitors, including archway metal detectors, handheld wands, and X-ray baggage scanners.” Source location Response from HM Prison and Probation Service
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 Conduct vulnerability assessments across the prison estate to understand drone risks and inform mitigation plans.
Verbatim wording from the response “We also work closely with law enforcement organisations to tackle prisons being targeted by drones. The Director General of the National Crime Agency has directed police chiefs to work with HMPPS to jointly tackle the threat of drones. For example, there are 400m restricted fly zones around all closed prisons and Young Offender Institutions. These restrictions make all unauthorised drone incursions a crime and support police and prison staff to disrupt illegal drone use. Additionally, we have developed comprehensive guidance and are delivering upskilling to staff to improve the response to drone activity impacting our prisons. HMPPS also conducts vulnerability assessments across the estate to understand the risk so that we can develop and implement plans to mitigate the threat.” Source location Response from HM Prison and Probation Service
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 Invest over £40 million in physical security across 34 prisons, including anti-drone measures at more than 15 priority prisons.
Verbatim wording from the response “HMPPS is aware of the available routes for contraband, such as drugs and mobile phones, to enter prisons and how they are influenced by factors such as security measures, geographical location and prisoner cohort. Due to this, our approach to conveyance is multi-faceted. In the 2025/2026 financial year, HMPPS is investing over £40m in physical security measures across 34 prisons, including £10m on anti-drone measures, such as window replacements, external window grilles and specialist netting in over 15 priority prisons.” Source location Response from HM Prison and Probation Service
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 Develop comprehensive guidance for responding to drone activity affecting prisons.
Verbatim wording from the response “We also work closely with law enforcement organisations to tackle prisons being targeted by drones. The Director General of the National Crime Agency has directed police chiefs to work with HMPPS to jointly tackle the threat of drones. For example, there are 400m restricted fly zones around all closed prisons and Young Offender Institutions. These restrictions make all unauthorised drone incursions a crime and support police and prison staff to disrupt illegal drone use. Additionally, we have developed comprehensive guidance and are delivering upskilling to staff to improve the response to drone activity impacting our prisons. HMPPS also conducts vulnerability assessments across the estate to understand the risk so that we can develop and implement plans to mitigate the threat.” Source location Response from HM Prison and Probation Service
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 Operate X-ray body scanners in all adult male closed prisons to detect and deter internally concealed illicit items.
Verbatim wording from the response “HMPPS utilises multiple countermeasures and initiatives to tackle the conveyance of drugs and mobile phones into our prisons. For example, all adult male closed prisons are equipped with X-ray body scanners, which are used to detect and deter the internal concealment of” Source location Response from HM Prison and Probation Service
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 Equip 54 priority establishments with enhanced gate security, including metal detectors and X-ray baggage scanners, to screen staff and visitors.
Verbatim wording from the response “illicit items by prisoners. Additionally, all public sector prisons have been provided with trace detection equipment, which is used to identify the presence of drugs on physical items. Furthermore, 54 priority establishments have airport-style enhanced gate security to screen staff and visitors, including archway metal detectors, handheld wands, and X-ray baggage scanners.” Source location Response from HM Prison and Probation Service
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 More definitive drug-related deaths statistics cannot currently cover later years because incomplete coroner data would reduce result quality.
Verbatim wording from the response “There is inevitably a considerable time lag before more definitive statistics of this type can be produced: the decision was taken for the 2023 publication to stop at 2019 because at the time the Coroner’s data for later years was far from complete, reducing the quality of the results. We hope to collaborate with ONS again to provide a further version of this publication in the future. We also keep the contents of our Official Statistics under continuous review, to ensure their compliance with the three pillars of the Code of Practice for Statistics; trustworthiness, quality and value.” Source location Response from HM Prison and Probation Service
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 HMPPS cannot publish a specific drug-related deaths category because such cases cannot be identified accurately within required publication timescales.
Verbatim wording from the response “With regard to the reporting of deaths in custody, we publish Official Safety in Custody Statistics quarterly, but do not have a specific category of ‘drug-related’ in those statistics. For administrative and statistical purposes our classification is by apparent cause of death. This has evolved specifically to help place reliable numbers of deaths in prison custody in the public domain without undue delay, and we do not use the category of ‘drug-related’ in published statistics because it is difficult to identify such cases accurately within the timescale required for our publications.” Source location Response from HM Prison and Probation Service
Open published response
Concerns raised 1 Failure to prevent unobserved removal and relocation of prohibited items during toilet visits by detained persons on close observations View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Steven Lee RUDDICK · 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
Steven Lee Ruddick was transported to University Hospital North Durham while en route to HMP Durham for an ankle check and died shortly after using the toilet in a police waiting room. The report identifies differences between police and GeoAmey/HM Prison Service procedures for observing detained people during toilet visits, which could allow prohibited items to be removed from the rectum without direct observation.
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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent unobserved removal and relocation of prohibited items during toilet visits by detained persons on close observations
Wider context from the report “It emerged during the evidence that there is a material difference between police procedures for managing a detained person on close observations and those of GeoAmey and, it is understood, HM Prison Service in relation to using the toilet in this case . In police custody, the detained person would be in standard cuffs and the officer would be present and observing directly during the toilet visit. In GeoAmey and Prison Service custody, in contrast, the detained person would be in a 1 metre closet chain and would be attached to the officer by means of a 1.5-2 metre chain and he/she would used the toilet without the officer observing directly . While this preserves the privacy and dignity of the detained person it can also, as in this scenario, potentially offer him/her the opportunity of removing prohibited items from the rectum without being observed and relocating them on his/her person . ████████ police and GeoAmey/HM Prison Service on this issue only emerged during the evidence of witnesses to the Inquest itself and it’s significance not predicted by either myself or any of the Interested Persons or their representatives before the Inquest. By that stage, MOJ had been stood down as an Interested Person (which was agreed across the board) since the Pre-Inquest Review in February 2025. Further, it was only established at the very end of the Inquest during submissions on Regulation 28 matters that the policy and procedures governing custody in the scenario here relevant is provided by PECS rather than by GeoAmey itself. Clearly, had either of these factors been different, then MOJ would have had a chance to contribute
” 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 Issue PECS suppliers a reflective direction and briefing on risk-based searching.
Verbatim wording from the response “PECS recognises the concerns raised in relation to searching following toilet visits. In response, suppliers searching standard operating procedures have been reviewed and confirmed as compliant with HMPPS policy and the PECS ‘Authority’ reflective direction and briefing around risk based searching to both PECS suppliers.” Source location Response from HM Prison and Probation Service
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 Review suppliers’ searching procedures and confirm their compliance with HMPPS policy and PECS requirements.
Verbatim wording from the response “PECS recognises the concerns raised in relation to searching following toilet visits. In response, suppliers searching standard operating procedures have been reviewed and confirmed as compliant with HMPPS policy and the PECS ‘Authority’ reflective direction and briefing around risk based searching to both PECS suppliers.” Source location Response from HM Prison and Probation Service
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing HMPPS supervision policy is sufficient; routine direct observation is not required except for formally assessed acute safety risks.
Verbatim wording from the response “HMPPS policy is explicit that, unless a prisoner is subject to a formally risk-assessed regime of constant supervision due to active suicide and/or self-harm risk, prisoners would not be supervised within toilet facilities in such close proximity to staff as to permit direct observation.” Source location Response from HM Prison and Probation Service
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 Reviewed supplier procedures and prescribed fully clothed rub-down searches are compliant and considered sufficient despite unavoidable residual risks.
Verbatim wording from the response “PECS recognises the concerns raised in relation to searching following toilet visits. In response, suppliers searching standard operating procedures have been reviewed and confirmed as compliant with HMPPS policy and the PECS ‘Authority’ reflective direction and briefing around risk based searching to both PECS suppliers.” Source location Response from HM Prison and Probation Service
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The escort chain remains a proportionate and appropriate restraint control, with alternatives considered only in exceptional, formally assessed acute-risk cases.
Verbatim wording from the response “The HMPPS Directorate of Security have been consulted and jointly considered the issues raised and advises that the continued use of the escort chain, rather than standard handcuffs, remains a proportionate and appropriate control measure for HMPPS external escorts.” Source location Response from HM Prison and Probation Service
Open published response
18 Nov 2025 Derrion Jack ADAMS · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 2 Failure of staffing benchmarks to account for operational pressures from contraband and psychoactive substance incidents View source Ongoing entry of novel psychoactive substances and other contraband into the prison View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Derrion Jack ADAMS · 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
Derrion Adams died at HMP Birmingham on 31 October 2024 after being found unresponsive in his cell and subsequently being pronounced deceased following a cardiac arrest. The report states that his death was due to toxicity from a substance. The principal concerns were the availability of drugs and contraband in the prison, surges in drug-related incidents, and staffing levels that were insufficient to ensure his cell call bell was answered within the target time, delaying identification and response.
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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure of staffing benchmarks to account for operational pressures from contraband and psychoactive substance incidents
Wider context from the report “6. The evidence was that HMP Birmingham is operating at its target staffing figures and has measures in place to deploy extra staff to areas of need in response to incidents. Additionally it is hoped that the introduction of tamper-proof vapes will limit use of psychoactive substances. However, my concern is that the current target staffing figures, which are based on historic bench marking and apply nationally, do not take into consideration the additional challenges to prison staff from contraband entering prisons via drones and, in particular, the burden placed on staff as a consequences of prisoners using psychoactive substances and other drugs . This concern is underlined by the fact that the staffing on the wing was not sufficient to ensure the call bell for Derrion's cell was answered within the target time resulting in a delay in identifying and responding to his cardiac arrest.
7. My overall concern is that current staffing benchmarks may not reflect the escalating operational pressures caused by the security threat from ████████ and intermittent surges in psychoactive substance incidents , leaving prison staff safety and welfare, and that of staff, at significant risk.
” 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Ongoing entry of novel psychoactive substances and other contraband into the prison
Wider context from the report “1. The inquest heard evidence from the Head of Drug Strategy and the Head of Safety at HMP Birmingham at the time of Derrion's death. Their evidence included that novel psychoactive substances and other contraband items were able to enter the prison via ████████ and this continues . The following statements were made in evidence "████████ are ruining the safety of the prison".
2. The Heads of Drug Strategy and Safety gave clear and credible evidence that they at HMP Birmingham are doing everything they can using the measures available to them to stop and intercept ████████ delivering to HMP Birmingham but these measures are often not successful because the sophistication of the criminals using ████████ to deliver contraband to prisons is "more sophisticated than us".
” 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 Conduct estate-wide vulnerability assessments to inform mitigation plans for drone-related threats.
Verbatim wording from the response “We are working closely with law enforcement partners and are supported by the National Crime Agency, to tackle drone-related criminality, and all closed prisons and young offender institutions are protected by 400-metre Restricted Fly Zones, making unauthorised incursions a criminal offence. Additionally, HMPPS has developed comprehensive guidance for staff, upskilling them to improve operational responses, and conducts vulnerability assessments across the estate to inform mitigation plans.” Source location Response from HM Prison and Probation Service
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 Complete a review of adult public-sector prison staffing models, including operational pressure impacts on daily resourcing.
Verbatim wording from the response “Recent work has been completed to review the underpinning staffing model for adult public sector prisons, including HMP Birmingham. This review has included consideration of the impact that changes to operational pressures have had on daily resourcing requirements. New models are currently at the implementation planning stage and remain subject to final decisions.” Source location Response from HM Prison and Probation Service
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 Develop comprehensive staff guidance to improve operational responses to drone-related threats.
Verbatim wording from the response “We are working closely with law enforcement partners and are supported by the National Crime Agency, to tackle drone-related criminality, and all closed prisons and young offender institutions are protected by 400-metre Restricted Fly Zones, making unauthorised incursions a criminal offence. Additionally, HMPPS has developed comprehensive guidance for staff, upskilling them to improve operational responses, and conducts vulnerability assessments across the estate to inform mitigation plans.” Source location Response from HM Prison and Probation Service
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 Develop implementation plans for new adult public-sector prison staffing models, subject to final decisions.
Verbatim wording from the response “Recent work has been completed to review the underpinning staffing model for adult public sector prisons, including HMP Birmingham. This review has included consideration of the impact that changes to operational pressures have had on daily resourcing requirements. New models are currently at the implementation planning stage and remain subject to final decisions.” Source location Response from HM Prison and Probation Service
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 Work with law-enforcement partners to tackle drone-related criminality.
Verbatim wording from the response “We are working closely with law enforcement partners and are supported by the National Crime Agency, to tackle drone-related criminality, and all closed prisons and young offender institutions are protected by 400-metre Restricted Fly Zones, making unauthorised incursions a criminal offence. Additionally, HMPPS has developed comprehensive guidance for staff, upskilling them to improve operational responses, and conducts vulnerability assessments across the estate to inform mitigation plans.” Source location Response from HM Prison and Probation Service
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 Invest in physical prison-security enhancements, including anti-drone measures, improved windows, specialist netting and external grilles.
Verbatim wording from the response “The Ministry of Justice (MoJ) and HMPPS are committed to deterring, detecting, and disrupting the use of drones around prisons in England and Wales. Our approach is multi-faceted, combining physical security countermeasures, technological innovation, intelligence exploitation, strengthened legislation, and collaboration across Government and with” Source location Response from HM Prison and Probation Service
Open published response
20 Oct 2025 Scott Stephen Berry · Prevention of Future Deaths report East Riding and Hull
View report summary
Concerns raised 2 Lack of access to Offender Delivery Programmes or therapeutic and progression units for unreleased IPP prisoners View source Delays in parole board review for unreleased IPP prisoners View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Scott Stephen 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
Scott Stephen Berry was a prisoner serving an Imprisonment for Public Protection sentence when, after expressing suicidal thoughts, he was found hanging on 12 October 2023. He was resuscitated and taken to hospital but died on 21 October 2023 after sustaining a hypoxic brain injury. The principal concern was that unreleased IPP prisoners may face prolonged detention, limited access to progression or therapeutic support, poor mental health and little hope of release, creating a risk of future deaths.
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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Lack of access to Offender Delivery Programmes or therapeutic and progression units for unreleased IPP prisoners
Wider context from the report “However, there still remains a large number of unreleased IPP prisoners in prison. For those who remain detained in prison, some many years after their original tariff, there is still a long period for them to wait for a review. These prisoners are, in many cases, still waiting for parole board review and not all have access to Offender Delivery Programmes or therapeutic and progression units to assist them .
These prisoners are suffering with their mental health and still have little hope of release. If action is not taken with regard to those still serving these sentences in prison, then there is a risk of future deaths occurring.
” 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Delays in parole board review for unreleased IPP prisoners
Wider context from the report “However, there still remains a large number of unreleased IPP prisoners in prison. For those who remain detained in prison, some many years after their original tariff, there is still a long period for them to wait for a review . These prisoners are, in many cases, still waiting for parole board review and not all have access to Offender Delivery Programmes or therapeutic and progression units to assist them.
These prisoners are suffering with their mental health and still have little hope of release. If action is not taken with regard to those still serving these sentences in prison, then there is a risk of future deaths occurring.
” 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 Update the Generic Parole Process Policy Framework to introduce presumed review intervals for IPP and DPP prisoners.
Verbatim wording from the response “I note that you raised concerns that IPP prisoners are waiting for a Parole Board review. The priority when listing cases is a matter for the Independent Parole Board. Nonetheless, HMPPS updated the Generic Parole Process Policy Framework in February 2025 and introduced a presumption for an 18-month period between parole reviews for IPP prisoners and 12 months for DPP (youth equivalent of IPP sentence) prisoners¹.” Source location Response from HM Prison & Probation Service
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 Publish and operate Progression Panel arrangements to place IPP prisoners on appropriate progression pathways with timely interventions.
Verbatim wording from the response “• We published the Progression Panel Policy Framework in July, and have already seen a significant number of panels recorded. These panels, comprising of HMPPS staff and wider partner agencies, ensure that those serving IPP sentences are on the right progression pathway, with access to the right interventions, at the right time.” Source location Response from HM Prison & Probation Service
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 Streamline recall documentation and require consideration of Risk Assessed Recall Review suitability.
Verbatim wording from the response “• HMPPS have streamlined recall documentation and added a direct request to consider suitability for Risk Assessed Recall Review (RARR) ensuring that the potential for a swifter re-release is firmly in the mind of the Probation Officer completing it.” Source location Response from HM Prison & Probation Service
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 Run the recall referral trial to extend the referral period and allow more time to consider Risk Assessed Recall Review.
Verbatim wording from the response “• The recall referral trial has begun; this will extend the period of time in which IPP prisoners must be referred to the Parole Board following recall with the intent of allowing more time for consideration of RARR.” Source location Response from HM Prison & Probation Service
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 Create the Phoenix Unit at HMP Aylesbury for IPP prisoners with red RAG ratings who are struggling to progress.
Verbatim wording from the response “• HMP Aylesbury is in the process of creating the Phoenix Unit, which will be a bespoke unit dedicated to support IPP prisoners with a red RAG rating who are struggling to progress in their sentence.” Source location Response from HM Prison & Probation Service
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 Priority for listing IPP parole reviews is determined by the independent Parole Board, not HMPPS.
Verbatim wording from the response “I note that you raised concerns that IPP prisoners are waiting for a Parole Board review. The priority when listing cases is a matter for the Independent Parole Board. Nonetheless, HMPPS updated the Generic Parole Process Policy Framework in February 2025 and introduced a presumption for an 18-month period between parole reviews for IPP prisoners and 12 months for DPP (youth equivalent of IPP sentence) prisoners¹.” Source location Response from HM Prison & Probation Service
Open published response
Concerns raised 3 Failure to keep aspirating fire detection system fault buzzers operational View source Failure to protect aspirating fire detection system control panels from deliberate tampering View source Lack of central oversight of aspirating fire detection system faults View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Richard Charles HUNT · 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 Charles HUNT was a serving prisoner at HMP Stocken who set fire to his cell on 11 July 2025, was taken to hospital, and died later that day from smoke inhalation. The report raises concerns that the aspirating fire detection system’s buzzer failed to sound because it had been deliberately disabled or tampered with, and that similar issues were found across the prison estate without central oversight of faults.
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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to keep aspirating fire detection system fault buzzers operational
Wider context from the report “On both occasions prior to setting fire to his cell, ████████ it is designed to trigger an alarm on a control panel which is housed in the Wing Office situated on each wing. The triggering of that alarm should not only display a light but also sound a buzzer to alert staff of a fault.
On the 19th March when Mr Hunt set fire to his cell on K Wing and on 11th July when he set fire to his cell on I Wing this buzzer did not sound.
On 19th March 2025, Mr Hunt himself raised the alarm by sounding his cell bell and was discovered. He required CPR and was hospitalised for 3 days. The aspirating fire alarm system did not sound an alarm in the K Wing office.
On 11th July the detection of Mr Hunt having set fire to his cell was fortuitous as an OSG was conducting an ACCT check on another prisoner in a nearby cell and smelt smoke. The alarm indication of a fault had been triggered 2 hours before this discovery and Mr Hunt’s cell had been smouldering for around this period of time undetected. Again, no buzzer was sounded.
Following the fire on the 19th March 2025, investigation revealed that the aspirating fire detection system buzzer with the Wing Office had been ‘disabled’ and it was believed to have been deliberately silenced for 12 months prior to the incident.
Following the fire and Mr Hunt’s death on the 11th July 2025, the aspirating fire detection system was inspected and reviewed across the HMP Stocken Estate by ADT alarms, who are contracted to maintain the system. That inspection revealed that the reason the alarm on I wing, which was triggered but did not sound the buzzer, was because the control panel in the Wing Office (and in which the buzzer was housed) had been deliberately tampered with, by the insertion of a rubber glove between the connectors thereby disabling the buzzer.
Further inspection of the aspirating fire detection system panels across the HMP Stocken Estate found for example the control panel on L Wing had been vandalised ████████ and that control panel units in other Wings including segregation had been deliberately forced open to gain access.
I further understand that the aspirating fire detection system panels on the Wings do not link with the main Control Room, meaning there is no central oversight of faults (whether deliberate coverd or indicating a fire) for action to be immediately taken.
Whilst HMP Stocken may have a system of maintenance of the aspirating fire detection system within the prison, that maintenance system is futile if staff are going to deliberately tamper with that system to disable the buzzer which is designed to alert them as to risk. This is not an isolated occurrence and is systemic across the HMP Stocken Estate.
” 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to protect aspirating fire detection system control panels from deliberate tampering
Wider context from the report “On both occasions prior to setting fire to his cell, ████████ it is designed to trigger an alarm on a control panel which is housed in the Wing Office situated on each wing. The triggering of that alarm should not only display a light but also sound a buzzer to alert staff of a fault.
On the 19th March when Mr Hunt set fire to his cell on K Wing and on 11th July when he set fire to his cell on I Wing this buzzer did not sound.
On 19th March 2025, Mr Hunt himself raised the alarm by sounding his cell bell and was discovered. He required CPR and was hospitalised for 3 days. The aspirating fire alarm system did not sound an alarm in the K Wing office.
On 11th July the detection of Mr Hunt having set fire to his cell was fortuitous as an OSG was conducting an ACCT check on another prisoner in a nearby cell and smelt smoke. The alarm indication of a fault had been triggered 2 hours before this discovery and Mr Hunt’s cell had been smouldering for around this period of time undetected. Again, no buzzer was sounded.
Following the fire on the 19th March 2025, investigation revealed that the aspirating fire detection system buzzer with the Wing Office had been ‘disabled’ and it was believed to have been deliberately silenced for 12 months prior to the incident.
Following the fire and Mr Hunt’s death on the 11th July 2025, the aspirating fire detection system was inspected and reviewed across the HMP Stocken Estate by ADT alarms, who are contracted to maintain the system. That inspection revealed that the reason the alarm on I wing, which was triggered but did not sound the buzzer, was because the control panel in the Wing Office (and in which the buzzer was housed) had been deliberately tampered with, by the insertion of a rubber glove between the connectors thereby disabling the buzzer.
Further inspection of the aspirating fire detection system panels across the HMP Stocken Estate found for example the control panel on L Wing had been vandalised ████████ and that control panel units in other Wings including segregation had been deliberately forced open to gain access.
I further understand that the aspirating fire detection system panels on the Wings do not link with the main Control Room, meaning there is no central oversight of faults (whether deliberate coverd or indicating a fire) for action to be immediately taken.
Whilst HMP Stocken may have a system of maintenance of the aspirating fire detection system within the prison, that maintenance system is futile if staff are going to deliberately tamper with that system to disable the buzzer which is designed to alert them as to risk. This is not an isolated occurrence and is systemic across the HMP Stocken Estate.
” 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Lack of central oversight of aspirating fire detection system faults
Wider context from the report “On both occasions prior to setting fire to his cell, ████████ it is designed to trigger an alarm on a control panel which is housed in the Wing Office situated on each wing. The triggering of that alarm should not only display a light but also sound a buzzer to alert staff of a fault.
On the 19th March when Mr Hunt set fire to his cell on K Wing and on 11th July when he set fire to his cell on I Wing this buzzer did not sound.
On 19th March 2025, Mr Hunt himself raised the alarm by sounding his cell bell and was discovered. He required CPR and was hospitalised for 3 days. The aspirating fire alarm system did not sound an alarm in the K Wing office.
On 11th July the detection of Mr Hunt having set fire to his cell was fortuitous as an OSG was conducting an ACCT check on another prisoner in a nearby cell and smelt smoke. The alarm indication of a fault had been triggered 2 hours before this discovery and Mr Hunt’s cell had been smouldering for around this period of time undetected. Again, no buzzer was sounded.
Following the fire on the 19th March 2025, investigation revealed that the aspirating fire detection system buzzer with the Wing Office had been ‘disabled’ and it was believed to have been deliberately silenced for 12 months prior to the incident.
Following the fire and Mr Hunt’s death on the 11th July 2025, the aspirating fire detection system was inspected and reviewed across the HMP Stocken Estate by ADT alarms, who are contracted to maintain the system. That inspection revealed that the reason the alarm on I wing, which was triggered but did not sound the buzzer, was because the control panel in the Wing Office (and in which the buzzer was housed) had been deliberately tampered with, by the insertion of a rubber glove between the connectors thereby disabling the buzzer.
Further inspection of the aspirating fire detection system panels across the HMP Stocken Estate found for example the control panel on L Wing had been vandalised ████████ and that control panel units in other Wings including segregation had been deliberately forced open to gain access.
I further understand that the aspirating fire detection system panels on the Wings do not link with the main Control Room, meaning there is no central oversight of faults (whether deliberate coverd or indicating a fire) for action to be immediately taken.
Whilst HMP Stocken may have a system of maintenance of the aspirating fire detection system within the prison, that maintenance system is futile if staff are going to deliberately tamper with that system to disable the buzzer which is designed to alert them as to risk. This is not an isolated occurrence and is systemic across the HMP Stocken Estate.
” 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 Communicate staff fire-safety responsibilities, reporting requirements and disciplinary consequences through meetings, blogs, briefings and senior-team correspondence.
Verbatim wording from the response “Following the concerns regarding the tampering of fire alarm control panels the Governor of HMP Stocken commissioned two fact-finding investigations to determine if staff may have been involved with the tampering of fire safety equipment, and if so whether those staff could be identified. While it has not been possible to identify any individuals, the Governor has made clear to staff the seriousness of such action, and that anyone engaging in any tampering of the fire alarm system will be subject to formal disciplinary action.” Source location Response from HM Prison and Probation Service
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 Restrict access to fire-alarm-panel keys to authorised maintenance and health-and-safety personnel.
Verbatim wording from the response “Following Mr Hunt’s death and the discovery that the fire panel located in the wing office had been tampered with, preventing the buzzer from sounding, immediate action was taken and a replacement fire panel installed. The prison’s Health and Safety team was further tasked with undertaking a review of the physical security of the fire alarm panels, which found that the panels could be accessed, posing a significant risk to operational safety. Work is ongoing to rectify this issue, with access to fire alarm panel keys to be restricted to authorised personnel only - namely ADT (the fire alarm installer and maintainer), Amey, and Health & Safety advisors, preventing further unauthorised access and ensuring compliance with safety protocols.” Source location Response from HM Prison and Probation Service
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 Use maintenance-response data to assure that fire-panel fault alerts are unsilenced and remaining issues are rectified.
Verbatim wording from the response “Nationally, in response to the March incident, on 3 April 2025 a Service Managers Instruction (SMI) was issued to all prison maintenance teams, reiterating their responsibility to ensure that all fire safety equipment is maintained in an efficient and fully operational condition. Data from responses to this instruction is being used to provide assurance that panels’ fault alerts are un silenced, and that action is being taken to rectify any remaining issues.” Source location Response from HM Prison and Probation Service
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 Complete 19 of the 26 fire-safety actions identified in the strategic action plan.
Verbatim wording from the response “identified 26 actions including high level requests for changes to fire safety and detection systems as well as tasks for immediate actions such as replacing sounders on the fire alarm panels. To date, 19 of these actions have been completed with most of the remaining actions awaiting approval of spending bids.” Source location Response from HM Prison and Probation Service
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 Replace fire-alarm systems on I and K wings and the Care and Separation Unit, with networking to the Control Room.
Verbatim wording from the response “In regards to your concern regarding the link between the fault panels on the wings and the main Control Room, in November 2025 Ministry of Justice Property Directorate issued a mandate for the full replacement of the fire alarm systems on I and K wings and the Care and Separation Unit, with full networking back to the Control Room master fire alarm panel to allow any alarms or faults raised by the local fire alarm control panels on those wings to be visible in the Control Room. This is currently in the design and tendering stage with the intention that it will be rolled out as soon as practicable.” Source location Response from HM Prison and Probation Service
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 a daily morning-meeting feedback system for discussing and reporting fire faults and tracking follow-up.
Verbatim wording from the response “Locally, the Governor has introduced a daily feedback system into the morning meeting he chairs whereby all fire faults are discussed and reported. There is a specific focus on any alarms which are not sounding when in fault, and alarms which are continually sounding. This is to ensure that follow-up actions are completed where appropriate by prison staff and also that the maintenance provider is made aware of faults which require attention.” Source location Response from HM Prison and Probation Service
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 Install a replacement fire panel after discovering that the existing panel had been tampered with.
Verbatim wording from the response “Following Mr Hunt’s death and the discovery that the fire panel located in the wing office had been tampered with, preventing the buzzer from sounding, immediate action was taken and a replacement fire panel installed. The prison’s Health and Safety team was further tasked with undertaking a review of the physical security of the fire alarm panels, which found that the panels could be accessed, posing a significant risk to operational safety. Work is ongoing to rectify this issue, with access to fire alarm panel keys to be restricted to authorised personnel only - namely ADT (the fire alarm installer and maintainer), Amey, and Health & Safety advisors, preventing further unauthorised access and ensuring compliance with safety protocols.” Source location Response from HM Prison and Probation Service
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 Mandate that tampering with fire equipment is a disciplinary offence and will be investigated.
Verbatim wording from the response “On 15 August 2025 a Governor’s Order was issued mandating that tampering with fire equipment is a disciplinary offence and will be investigated. This has been reiterated at a face to face, full staff meeting on 24th September 2025, in weekly blogs and in briefings to staff issued in April, July and August 2025. These set out clearly staff’s personal responsibility for fire safety, reminding staff of the need to ensure they understand the equipment in place and to report all faults and issues immediately, signposting how this is done and where support can be sought from. The Governor has also met with and written to the senior team outlining their responsibilities within their functions with regards to fire safety.” Source location Response from HM Prison and Probation Service
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 Commission fact-finding investigations into possible staff involvement in fire-equipment tampering.
Verbatim wording from the response “Following the concerns regarding the tampering of fire alarm control panels the Governor of HMP Stocken commissioned two fact-finding investigations to determine if staff may have been involved with the tampering of fire safety equipment, and if so whether those staff could be identified. While it has not been possible to identify any individuals, the Governor has made clear to staff the seriousness of such action, and that anyone engaging in any tampering of the fire alarm system will be subject to formal disciplinary action.” Source location Response from HM Prison and Probation Service
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 Issue a national instruction requiring prison maintenance teams to keep fire-safety equipment efficient and fully operational.
Verbatim wording from the response “Nationally, in response to the March incident, on 3 April 2025 a Service Managers Instruction (SMI) was issued to all prison maintenance teams, reiterating their responsibility to ensure that all fire safety equipment is maintained in an efficient and fully operational condition. Data from responses to this instruction is being used to provide assurance that panels’ fault alerts are un silenced, and that action is being taken to rectify any remaining issues.” Source location Response from HM Prison and Probation Service
Open published response
7 Oct 2025 Angela Christine Thompson · Prevention of Future Deaths report East Riding and Hull
View report summary
Concerns raised 1 Lack of liaison between prison medical services and local psychiatric services for prisoners with ongoing psychiatric issues at release 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
Angela Christine Thompson · 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
Angela Christine Thompson died after being struck by a taxi on 11 April 2022, following repeated attempts to place herself in the path of traffic. The report raised concern about inadequate liaison between prison medical services and community psychiatric services when people with ongoing psychiatric issues are released from custody, particularly when the prison is geographically distant from their home.
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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Lack of liaison between prison medical services and local psychiatric services for prisoners with ongoing psychiatric issues at release
Wider context from the report “Evidence was heard that in some instances within the prison estate of England and Wales, there may be a lack of liaison in patients who have on-going psychiatric issues at the time of release from custody between the prison medical services and the psychiatric services in the area where the released prisoner lives . This was felt to be of particular concern when a person is incarcerated at a prison geographically distant from their home address . Evidence suggested that such liaison would ensure and enhance continuity of care following release from prison.
” Open source report
24 Sep 2025 Steven HART · Prevention of Future Deaths report Bedfordshire and Luton
View report summary
Concerns raised 7 Delays in addressing identified cell-safety concerns View source Failure to remove unsafe cells from use View source Failure to ensure observation panels cannot be opened from inside to create ligature opportunities View source Failure to escalate risk after incidents requiring review of observations or ligature controls View source Failure to communicate relevant risk information through handovers and records View source Failure to carry out required observations at the appropriate level and standard View source Failure to report serious self-harm incidents and trigger further assessment View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Steven HART · 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
Steven Hart was remanded to HMP Bedford in November 2022 and, after episodes of self-harm and deterioration in his mental health, was found unresponsive in his cell on 25 March 2023 after using a ligature attached to a faulty observation panel. He was taken to hospital and died on 29 March 2023 from asphyxiation due to hanging. The principal concerns were failures in cell safety, communication and handovers, mental health assessment, and the carrying out and escalation of observations after self-harm incidents.
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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Delays in addressing identified cell-safety concerns
Wider context from the report “1. Failure to Adequately Monitor and Audit Cells for Ligature Points
Mr Hart was placed in a “safer cell” designed to have no ligature points. However, the observation panel ████████ was broken, ████████ which he was able to thread a ligature and hang himself.
Staff and witnesses confirmed that the damage to the cell door was known, and that maintenance was generally responsive, but the cell was not taken out of use despite the increased risk.
The prison’s own post-inquest review acknowledged that the design of the observation panels allowed prisoners to open them from inside, creating an opportunity for self-harm. Interim and permanent solutions were only implemented after the Inquest had commenced nearly two and a half years after Steven's death indicating a likely failure to tackle safety concerns promptly or appropriately .
2. Failure to Effectively Communicate Risk and Incidents
There was a general failure to distribute and communicate relevant observations and concerns regarding Mr Hart’s mental state. Staff often did not have time to receive handovers or read current and previous ACCT (Assessment, Care in Custody and Teamwork) documents during their shift. After a serious self-harm incident with Steven involving ████████ the officer involved failed to report the incident to OSCAR 1 (the officer in charge), as required by protocol. He simply removed the ████████ and did not conduct any further assessment or review of Steven. This failure prevented a multi-disciplinary review and possible escalation of risk management. The night shift handover on 25 March 2023 was insufficient, with lack of vital information provided to the receiving officer, leading to inadequate understanding of Mr Hart’s risk.
3. Failure to Carry Out Appropriate Observations
Observations of Mr Hart were reduced from constant supervision to four irregular checks per hour, despite ongoing risk factors and recent self-harm attempts. CCTV evidence suggested that required observations were not always carried out to the proper standard, and some checks may not have been performed at all. The officer insisted they were carried out, although CCTV evidence strongly suggested that was improbable. The jury found that the failure to call OSCAR 1 after the telephone cord incident directly impacted Mr Hart, as it possibly prevented a further ACCT review and escalation of observations or removal of ligature materials.
The death of Steven Hart was contributed to by systemic failings in cell safety, communication, and observation practices. There were, paradoxically, along-side poor practice and care, examples of exceptionally good practice by a group of officers of which several have left the prison service. There was generally a failure to implement robust systems for cell safety audits, enforce effective communication and handover protocols, and ensure strict compliance with observation requirements for 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to remove unsafe cells from use
Wider context from the report “1. Failure to Adequately Monitor and Audit Cells for Ligature Points
Mr Hart was placed in a “safer cell” designed to have no ligature points. However, the observation panel ████████ was broken, ████████ which he was able to thread a ligature and hang himself.
Staff and witnesses confirmed that the damage to the cell door was known, and that maintenance was generally responsive, but the cell was not taken out of use despite the increased risk .
The prison’s own post-inquest review acknowledged that the design of the observation panels allowed prisoners to open them from inside, creating an opportunity for self-harm. Interim and permanent solutions were only implemented after the Inquest had commenced nearly two and a half years after Steven's death indicating a likely failure to tackle safety concerns promptly or appropriately.
2. Failure to Effectively Communicate Risk and Incidents
There was a general failure to distribute and communicate relevant observations and concerns regarding Mr Hart’s mental state. Staff often did not have time to receive handovers or read current and previous ACCT (Assessment, Care in Custody and Teamwork) documents during their shift. After a serious self-harm incident with Steven involving ████████ the officer involved failed to report the incident to OSCAR 1 (the officer in charge), as required by protocol. He simply removed the ████████ and did not conduct any further assessment or review of Steven. This failure prevented a multi-disciplinary review and possible escalation of risk management. The night shift handover on 25 March 2023 was insufficient, with lack of vital information provided to the receiving officer, leading to inadequate understanding of Mr Hart’s risk.
3. Failure to Carry Out Appropriate Observations
Observations of Mr Hart were reduced from constant supervision to four irregular checks per hour, despite ongoing risk factors and recent self-harm attempts. CCTV evidence suggested that required observations were not always carried out to the proper standard, and some checks may not have been performed at all. The officer insisted they were carried out, although CCTV evidence strongly suggested that was improbable. The jury found that the failure to call OSCAR 1 after the telephone cord incident directly impacted Mr Hart, as it possibly prevented a further ACCT review and escalation of observations or removal of ligature materials.
The death of Steven Hart was contributed to by systemic failings in cell safety, communication, and observation practices. There were, paradoxically, along-side poor practice and care, examples of exceptionally good practice by a group of officers of which several have left the prison service. There was generally a failure to implement robust systems for cell safety audits, enforce effective communication and handover protocols, and ensure strict compliance with observation requirements for 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure observation panels cannot be opened from inside to create ligature opportunities
Wider context from the report “1. Failure to Adequately Monitor and Audit Cells for Ligature Points
Mr Hart was placed in a “safer cell” designed to have no ligature points. However, the observation panel ████████ was broken, ████████ which he was able to thread a ligature and hang himself.
Staff and witnesses confirmed that the damage to the cell door was known, and that maintenance was generally responsive, but the cell was not taken out of use despite the increased risk.
The prison’s own post-inquest review acknowledged that the design of the observation panels allowed prisoners to open them from inside, creating an opportunity for self-harm . Interim and permanent solutions were only implemented after the Inquest had commenced nearly two and a half years after Steven's death indicating a likely failure to tackle safety concerns promptly or appropriately.
2. Failure to Effectively Communicate Risk and Incidents
There was a general failure to distribute and communicate relevant observations and concerns regarding Mr Hart’s mental state. Staff often did not have time to receive handovers or read current and previous ACCT (Assessment, Care in Custody and Teamwork) documents during their shift. After a serious self-harm incident with Steven involving ████████ the officer involved failed to report the incident to OSCAR 1 (the officer in charge), as required by protocol. He simply removed the ████████ and did not conduct any further assessment or review of Steven. This failure prevented a multi-disciplinary review and possible escalation of risk management. The night shift handover on 25 March 2023 was insufficient, with lack of vital information provided to the receiving officer, leading to inadequate understanding of Mr Hart’s risk.
3. Failure to Carry Out Appropriate Observations
Observations of Mr Hart were reduced from constant supervision to four irregular checks per hour, despite ongoing risk factors and recent self-harm attempts. CCTV evidence suggested that required observations were not always carried out to the proper standard, and some checks may not have been performed at all. The officer insisted they were carried out, although CCTV evidence strongly suggested that was improbable. The jury found that the failure to call OSCAR 1 after the telephone cord incident directly impacted Mr Hart, as it possibly prevented a further ACCT review and escalation of observations or removal of ligature materials.
The death of Steven Hart was contributed to by systemic failings in cell safety, communication, and observation practices. There were, paradoxically, along-side poor practice and care, examples of exceptionally good practice by a group of officers of which several have left the prison service. There was generally a failure to implement robust systems for cell safety audits, enforce effective communication and handover protocols, and ensure strict compliance with observation requirements for 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate risk after incidents requiring review of observations or ligature controls
Wider context from the report “1. Failure to Adequately Monitor and Audit Cells for Ligature Points
Mr Hart was placed in a “safer cell” designed to have no ligature points. However, the observation panel ████████ was broken, ████████ which he was able to thread a ligature and hang himself.
Staff and witnesses confirmed that the damage to the cell door was known, and that maintenance was generally responsive, but the cell was not taken out of use despite the increased risk.
The prison’s own post-inquest review acknowledged that the design of the observation panels allowed prisoners to open them from inside, creating an opportunity for self-harm. Interim and permanent solutions were only implemented after the Inquest had commenced nearly two and a half years after Steven's death indicating a likely failure to tackle safety concerns promptly or appropriately.
2. Failure to Effectively Communicate Risk and Incidents
There was a general failure to distribute and communicate relevant observations and concerns regarding Mr Hart’s mental state. Staff often did not have time to receive handovers or read current and previous ACCT (Assessment, Care in Custody and Teamwork) documents during their shift. After a serious self-harm incident with Steven involving ████████ the officer involved failed to report the incident to OSCAR 1 (the officer in charge), as required by protocol. He simply removed the ████████ and did not conduct any further assessment or review of Steven. This failure prevented a multi-disciplinary review and possible escalation of risk management. The night shift handover on 25 March 2023 was insufficient, with lack of vital information provided to the receiving officer, leading to inadequate understanding of Mr Hart’s risk.
3. Failure to Carry Out Appropriate Observations
Observations of Mr Hart were reduced from constant supervision to four irregular checks per hour, despite ongoing risk factors and recent self-harm attempts. CCTV evidence suggested that required observations were not always carried out to the proper standard, and some checks may not have been performed at all. The officer insisted they were carried out, although CCTV evidence strongly suggested that was improbable. The jury found that the failure to call OSCAR 1 after the telephone cord incident directly impacted Mr Hart, as it possibly prevented a further ACCT review and escalation of observations or removal of ligature materials .
The death of Steven Hart was contributed to by systemic failings in cell safety, communication, and observation practices. There were, paradoxically, along-side poor practice and care, examples of exceptionally good practice by a group of officers of which several have left the prison service. There was generally a failure to implement robust systems for cell safety audits, enforce effective communication and handover protocols, and ensure strict compliance with observation requirements for 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate relevant risk information through handovers and records
Wider context from the report “1. Failure to Adequately Monitor and Audit Cells for Ligature Points
Mr Hart was placed in a “safer cell” designed to have no ligature points. However, the observation panel ████████ was broken, ████████ which he was able to thread a ligature and hang himself.
Staff and witnesses confirmed that the damage to the cell door was known, and that maintenance was generally responsive, but the cell was not taken out of use despite the increased risk.
The prison’s own post-inquest review acknowledged that the design of the observation panels allowed prisoners to open them from inside, creating an opportunity for self-harm. Interim and permanent solutions were only implemented after the Inquest had commenced nearly two and a half years after Steven's death indicating a likely failure to tackle safety concerns promptly or appropriately.
2. Failure to Effectively Communicate Risk and Incidents
There was a general failure to distribute and communicate relevant observations and concerns regarding Mr Hart’s mental state . Staff often did not have time to receive handovers or read current and previous ACCT (Assessment, Care in Custody and Teamwork) documents during their shift . After a serious self-harm incident with Steven involving ████████ the officer involved failed to report the incident to OSCAR 1 (the officer in charge), as required by protocol. He simply removed the ████████ and did not conduct any further assessment or review of Steven. This failure prevented a multi-disciplinary review and possible escalation of risk management. The night shift handover on 25 March 2023 was insufficient, with lack of vital information provided to the receiving officer , leading to inadequate understanding of Mr Hart’s risk.
3. Failure to Carry Out Appropriate Observations
Observations of Mr Hart were reduced from constant supervision to four irregular checks per hour, despite ongoing risk factors and recent self-harm attempts. CCTV evidence suggested that required observations were not always carried out to the proper standard, and some checks may not have been performed at all. The officer insisted they were carried out, although CCTV evidence strongly suggested that was improbable. The jury found that the failure to call OSCAR 1 after the telephone cord incident directly impacted Mr Hart, as it possibly prevented a further ACCT review and escalation of observations or removal of ligature materials.
The death of Steven Hart was contributed to by systemic failings in cell safety, communication, and observation practices. There were, paradoxically, along-side poor practice and care, examples of exceptionally good practice by a group of officers of which several have left the prison service. There was generally a failure to implement robust systems for cell safety audits, enforce effective communication and handover protocols, and ensure strict compliance with observation requirements for 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out required observations at the appropriate level and standard
Wider context from the report “1. Failure to Adequately Monitor and Audit Cells for Ligature Points
Mr Hart was placed in a “safer cell” designed to have no ligature points. However, the observation panel ████████ was broken, ████████ which he was able to thread a ligature and hang himself.
Staff and witnesses confirmed that the damage to the cell door was known, and that maintenance was generally responsive, but the cell was not taken out of use despite the increased risk.
The prison’s own post-inquest review acknowledged that the design of the observation panels allowed prisoners to open them from inside, creating an opportunity for self-harm. Interim and permanent solutions were only implemented after the Inquest had commenced nearly two and a half years after Steven's death indicating a likely failure to tackle safety concerns promptly or appropriately.
2. Failure to Effectively Communicate Risk and Incidents
There was a general failure to distribute and communicate relevant observations and concerns regarding Mr Hart’s mental state. Staff often did not have time to receive handovers or read current and previous ACCT (Assessment, Care in Custody and Teamwork) documents during their shift. After a serious self-harm incident with Steven involving ████████ the officer involved failed to report the incident to OSCAR 1 (the officer in charge), as required by protocol. He simply removed the ████████ and did not conduct any further assessment or review of Steven. This failure prevented a multi-disciplinary review and possible escalation of risk management. The night shift handover on 25 March 2023 was insufficient, with lack of vital information provided to the receiving officer, leading to inadequate understanding of Mr Hart’s risk.
3. Failure to Carry Out Appropriate Observations
Observations of Mr Hart were reduced from constant supervision to four irregular checks per hour, despite ongoing risk factors and recent self-harm attempts . CCTV evidence suggested that required observations were not always carried out to the proper standard, and some checks may not have been performed at all . The officer insisted they were carried out, although CCTV evidence strongly suggested that was improbable. The jury found that the failure to call OSCAR 1 after the telephone cord incident directly impacted Mr Hart, as it possibly prevented a further ACCT review and escalation of observations or removal of ligature materials.
The death of Steven Hart was contributed to by systemic failings in cell safety, communication, and observation practices. There were, paradoxically, along-side poor practice and care, examples of exceptionally good practice by a group of officers of which several have left the prison service. There was generally a failure to implement robust systems for cell safety audits, enforce effective communication and handover protocols, and ensure strict compliance with observation requirements for 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to report serious self-harm incidents and trigger further assessment
Wider context from the report “1. Failure to Adequately Monitor and Audit Cells for Ligature Points
Mr Hart was placed in a “safer cell” designed to have no ligature points. However, the observation panel ████████ was broken, ████████ which he was able to thread a ligature and hang himself.
Staff and witnesses confirmed that the damage to the cell door was known, and that maintenance was generally responsive, but the cell was not taken out of use despite the increased risk.
The prison’s own post-inquest review acknowledged that the design of the observation panels allowed prisoners to open them from inside, creating an opportunity for self-harm. Interim and permanent solutions were only implemented after the Inquest had commenced nearly two and a half years after Steven's death indicating a likely failure to tackle safety concerns promptly or appropriately.
2. Failure to Effectively Communicate Risk and Incidents
There was a general failure to distribute and communicate relevant observations and concerns regarding Mr Hart’s mental state. Staff often did not have time to receive handovers or read current and previous ACCT (Assessment, Care in Custody and Teamwork) documents during their shift. After a serious self-harm incident with Steven involving ████████ the officer involved failed to report the incident to OSCAR 1 (the officer in charge), as required by protocol . He simply removed the ████████ and did not conduct any further assessment or review of Steven. This failure prevented a multi-disciplinary review and possible escalation of risk management. The night shift handover on 25 March 2023 was insufficient, with lack of vital information provided to the receiving officer, leading to inadequate understanding of Mr Hart’s risk.
3. Failure to Carry Out Appropriate Observations
Observations of Mr Hart were reduced from constant supervision to four irregular checks per hour, despite ongoing risk factors and recent self-harm attempts. CCTV evidence suggested that required observations were not always carried out to the proper standard, and some checks may not have been performed at all. The officer insisted they were carried out, although CCTV evidence strongly suggested that was improbable. The jury found that the failure to call OSCAR 1 after the telephone cord incident directly impacted Mr Hart, as it possibly prevented a further ACCT review and escalation of observations or removal of ligature materials.
The death of Steven Hart was contributed to by systemic failings in cell safety, communication, and observation practices. There were, paradoxically, along-side poor practice and care, examples of exceptionally good practice by a group of officers of which several have left the prison service. There was generally a failure to implement robust systems for cell safety audits, enforce effective communication and handover protocols, and ensure strict compliance with observation requirements for vulnerable prisoners.
” 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 Investigate serious incidents, document findings, and action and monitor resulting recommendations.
Verbatim wording from the response “All serious incidents are now investigated thoroughly, with any findings documented. Recommendations arising from these investigations are actioned and monitored, ensuring improvement is implemented where appropriate. Any themes identified through investigations are used to inform staff training and where necessary performance management, ensuring continuous learning is taking place and embedded into practice.” Source location Response from HM Prison & Probation Service
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 Restore ligature-resistant cells to serviceable condition using approved lockable observation hatches.
Verbatim wording from the response “I can confirm that interim measures have been put in place at HMP Bedford to ensure that the ligature-resistant (LR) cells are now serviceable. The LR cell observation panels have temporarily been replaced with an approved lockable observation hatch. A full review of all LR doors has been completed, alongside an urgent assessment of the current door and observation panel design. Additionally, Government Facilities Services Limited has undertaken a further review of the locking mechanism within the LR cell observation panels to ensure they remain fully serviceable. In the longer term, a proposal to replace the existing LR cell observation panels with a model that meets current safety specifications – designed to reduce the risk of prisoners from opening them inside the cell - has been issued for tender.” Source location Response from HM Prison & Probation Service
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 Remove cells with significant defects from use and document and monitor remedial work until they are serviceable.
Verbatim wording from the response “Furthermore, the prison is taking a more proactive approach to identifying cell defects. Daily accommodation fabric checks (AFCs) are in place and carried out consistently throughout the establishment. AFCs are now subject to additional scrutiny and are designed to incorporate checks to identify any damage or deterioration of individual cells. Should a significant defect be identified during these checks, the cell will be immediately taken out of use until remedial work has been carried out and the cell is returned to a serviceable condition. Where a cell requires remedial work, the process is documented and monitored to ensure a timely resolution and accountability.” Source location Response from HM Prison & Probation Service
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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 Remind staff and provide additional training and support on escalating incidents and conducting ACCT reviews when risk increases.
Verbatim wording from the response “Staff have been reminded, and received additional training and support where necessary, on the importance of escalating incidents and ensuring that ACCT reviews take place when risk increases.” Source location Response from HM Prison & Probation Service
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 Issue a tender proposal to replace ligature-resistant observation panels with a model meeting current safety specifications.
Verbatim wording from the response “I can confirm that interim measures have been put in place at HMP Bedford to ensure that the ligature-resistant (LR) cells are now serviceable. The LR cell observation panels have temporarily been replaced with an approved lockable observation hatch. A full review of all LR doors has been completed, alongside an urgent assessment of the current door and observation panel design. Additionally, Government Facilities Services Limited has undertaken a further review of the locking mechanism within the LR cell observation panels to ensure they remain fully serviceable. In the longer term, a proposal to replace the existing LR cell observation panels with a model that meets current safety specifications – designed to reduce the risk of prisoners from opening them inside the cell - has been issued for tender.” Source location Response from HM Prison & Probation Service
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 Strengthen shift handovers through clearer risk-information sharing expectations and allocated time for comprehensive handovers.
Verbatim wording from the response “Handover procedures have also been strengthened to ensure that vital information is communicated effectively. Staff are supported through clearer expectations in relation to information sharing when there is evidence of a prisoners change to risk or presentation. Time has been allocated to facilitate comprehensive handovers between shifts, particularly in relation to those who are being supported by the Assessment, Care in Custody and Teamwork (ACCT) process.” Source location Response from HM Prison & Probation Service
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 Carry out daily accommodation fabric checks with additional scrutiny for cell damage or deterioration.
Verbatim wording from the response “Furthermore, the prison is taking a more proactive approach to identifying cell defects. Daily accommodation fabric checks (AFCs) are in place and carried out consistently throughout the establishment. AFCs are now subject to additional scrutiny and are designed to incorporate checks to identify any damage or deterioration of individual cells. Should a significant defect be identified during these checks, the cell will be immediately taken out of use until remedial work has been carried out and the cell is returned to a serviceable condition. Where a cell requires remedial work, the process is documented and monitored to ensure a timely resolution and accountability.” Source location Response from HM Prison & Probation Service
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 quality assurance for ACCT observations through regular CCTV sampling and review, escalation and investigation of discrepancies.
Verbatim wording from the response “In addition, a robust quality assurance process has been introduced for ACCT observations. This includes regular sampling and review of CCTV footage to confirm that ACCT observations are being completed and recorded in accordance with local policy. Where discrepancies are identified, they are escalated and investigated in line with the national protocol, with referrals to the police where appropriate.” Source location Response from HM Prison & Probation Service
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 Complete a full review of ligature-resistant doors and an urgent assessment of the door and observation-panel design.
Verbatim wording from the response “I can confirm that interim measures have been put in place at HMP Bedford to ensure that the ligature-resistant (LR) cells are now serviceable. The LR cell observation panels have temporarily been replaced with an approved lockable observation hatch. A full review of all LR doors has been completed, alongside an urgent assessment of the current door and observation panel design. Additionally, Government Facilities Services Limited has undertaken a further review of the locking mechanism within the LR cell observation panels to ensure they remain fully serviceable. In the longer term, a proposal to replace the existing LR cell observation panels with a model that meets current safety specifications – designed to reduce the risk of prisoners from opening them inside the cell - has been issued for tender.” Source location Response from HM Prison & Probation Service
Open published response
29 Jul 2025 Azroy Dawes-Clarke · Prevention of Future Deaths report Kent and Medway
View report summary
Concerns raised 7 Insufficient ACCT process training and competence among frontline and civilian staff View source Inconsistent or incomplete understanding of the legal framework for prison officers’ involvement in prisoner care and treatment View source Failure to provide bedding materials resistant to being ripped into ligatures View source Inconsistent decision-making about handcuffing prisoners during emergency hospital conveyance View source Lack of prison officers’ understanding of when the Mental Capacity Act applies in custody View source Unclear prison officer roles in conveying prisoners lacking capacity to hospital View source Failure to maintain prison officers’ first aid and basic life support competence during physical restraint View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Azroy Dawes-Clarke · 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
Azroy Dawes-Clarke died in hospital on 10 November 2021 after self-ligaturing in HMP Elmley, followed by restraint, cardiac and respiratory arrest, and further arrests during conveyance and treatment. The substantive concerns included inadequate communication and healthcare involvement, disproportionate and prolonged restraint, delays in recognising the arrest and starting CPR, unsuitable ligature-resistant materials, and gaps in staff training on ACCT procedures, first aid, basic life support, and the legal framework for medical emergencies.
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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Insufficient ACCT process training and competence among frontline and civilian staff
Wider context from the report “(2) Officers involved in Mr Dawes-Clarke’s ACCT process, described different experiences, familiarity and training in respect of the ACCT process. Some described finding new ACCT paperwork as difficult, others were unclear as to what matters should be recorded within the ACCT paperwork. Capacity to provide training to frontline officers and other civilian staff within the prison appeared to be limited.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Inconsistent or incomplete understanding of the legal framework for prison officers’ involvement in prisoner care and treatment
Wider context from the report “(4) Whilst the use of force paperwork completed following Mr Dawes-Clarke’s physical restraint made mention of the Mental Capacity Act 2005, none of the officers (including the individual who completed the paperwork) appeared to have any basic understanding of the circumstances when the Mental Capacity Act may apply in a custodial setting. Equally, many were unclear as to what their role would be in conveying a prisoner who lacked the capacity to consent to their conveyance to hospital in a medical emergency. Answers in respect of handcuffing prisoners for the purpose of conveying them to hospital in a medical emergency varied. Answers in respect of the legal framework which applied when prison officers are involved in care and treatment of a prisoner (the particular issue in the present case being the conveyance to hospital and the decision to dress him) were inconsistent or incomplete.
” 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to provide bedding materials resistant to being ripped into ligatures
Wider context from the report “(1) Despite being in a safer cell, dressed in an anti-ligature gown, Mr Dawes-Clarke was able to make a ligature from the bedding material in his cell. The material from which the mattress and pillow cover are made, permit strips to be ripped from them.
” 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Inconsistent decision-making about handcuffing prisoners during emergency hospital conveyance
Wider context from the report “(4) Whilst the use of force paperwork completed following Mr Dawes-Clarke’s physical restraint made mention of the Mental Capacity Act 2005, none of the officers (including the individual who completed the paperwork) appeared to have any basic understanding of the circumstances when the Mental Capacity Act may apply in a custodial setting. Equally, many were unclear as to what their role would be in conveying a prisoner who lacked the capacity to consent to their conveyance to hospital in a medical emergency. Answers in respect of handcuffing prisoners for the purpose of conveying them to hospital in a medical emergency varied. Answers in respect of the legal framework which applied when prison officers are involved in care and treatment of a prisoner (the particular issue in the present case being the conveyance to hospital and the decision to dress him) were inconsistent or incomplete.
” 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Lack of prison officers’ understanding of when the Mental Capacity Act applies in custody
Wider context from the report “(4) Whilst the use of force paperwork completed following Mr Dawes-Clarke’s physical restraint made mention of the Mental Capacity Act 2005, none of the officers (including the individual who completed the paperwork) appeared to have any basic understanding of the circumstances when the Mental Capacity Act may apply in a custodial setting. Equally, many were unclear as to what their role would be in conveying a prisoner who lacked the capacity to consent to their conveyance to hospital in a medical emergency. Answers in respect of handcuffing prisoners for the purpose of conveying them to hospital in a medical emergency varied. Answers in respect of the legal framework which applied when prison officers are involved in care and treatment of a prisoner (the particular issue in the present case being the conveyance to hospital and the decision to dress him) were inconsistent or incomplete.
” 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Unclear prison officer roles in conveying prisoners lacking capacity to hospital
Wider context from the report “(4) Whilst the use of force paperwork completed following Mr Dawes-Clarke’s physical restraint made mention of the Mental Capacity Act 2005, none of the officers (including the individual who completed the paperwork) appeared to have any basic understanding of the circumstances when the Mental Capacity Act may apply in a custodial setting. Equally, many were unclear as to what their role would be in conveying a prisoner who lacked the capacity to consent to their conveyance to hospital in a medical emergency. Answers in respect of handcuffing prisoners for the purpose of conveying them to hospital in a medical emergency varied. Answers in respect of the legal framework which applied when prison officers are involved in care and treatment of a prisoner (the particular issue in the present case being the conveyance to hospital and the decision to dress him) were inconsistent or incomplete.
” 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain prison officers’ first aid and basic life support competence during physical restraint
Wider context from the report “(3) Officers who were present during Mr Dawes-Clarke’s cardio-respiratory arrest had different training with regard to first aid and basic life support. During the course of the inquest, evidence was heard that whilst all uniformed prison officers would have regular training in respect of control and restraint, not all had recent (if any) training in first aid or basic life support. Some of the officers who gave evidence were unclear as to the correct response to a cardio respiratory arrest during physical restraint.
” 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 Continue rolling out SASH, speed training and ACCT upskilling to improve staff recognition of suicide and self-harm risks and case management.
Verbatim wording from the response “You raised that staff at inquest described different levels of familiarity and training in respect of the Assessment, Care in Custody and Teamwork (ACCT) process. HMP Elmley is committed to providing appropriate local training to upskill both operational and non-operational staff. This includes reinforcement of ACCT procedures through the ongoing rollout of Suicide and Self-Harm (SASH) training and “speed training” for bite-sized learning. Since Mr Dawes-Clarke’s death much work has been undertaken to help increase awareness and recognition of risk factors that increase the possibility of suicide and/or self-harm. A focus on continuing to upskill and support better case management as well as ACCT training for all staff working with prisoners is ongoing.” Source location Response from HM Prison and Probation Service
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 a cell design review to assess alternative materials meeting fire-safety and anti-ligature requirements for bedding.
Verbatim wording from the response “HMPPS are currently undertaking a cell design review which is looking at all aspects of cell design, including furniture and fittings, to ensure it takes account of developments in how prisoners are accommodated and improvements in what is currently available on the market. As part of this review, we will explore the possibility of using different materials which meet the stringent fire safety requirements and can also function as anti-ligature for bedding. The review is expected to conclude at the end of 2026.” Source location Response from HM Prison and Probation Service
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 Create bespoke first-on-scene care videos for prison officers and frontline staff covering potential emergency scenarios.
Verbatim wording from the response “To further improve our emergency contingency arrangements and to better equip employees to provide first-on-scene care (before medical assistance arrives), HMPPS have with St John Ambulance created a set of bespoke first-on-scene videos for Prison Officers and frontline staff. These provide practical guidance on what to do in several potential scenarios staff may come across in the course of their duties.” Source location Response from HM Prison and Probation Service
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 Attend ACCT case reviews to share experience and guidance with staff.
Verbatim wording from the response “The quality of ACCT management and compliance with policy is routinely assured, as per the nationally mandated quality assurance process, and findings from this assurance is fed back to staff to enable ongoing awareness and improvement. Additionally, Elmley’s safety team have devised an action plan to support improving case management including ACCT upskill training, attending case reviews to share experience and guidance and developing an improved booking system to enable better multi-disciplinary attendance and consistency of case co-ordinators.” Source location Response from HM Prison and Probation Service
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 Re-issue the national first aid refresher framework defining emergency first aid, workplace first aid and establishment cover requirements.
Verbatim wording from the response “You also raised that during the inquest it became clear that not all staff had recent training in first aid or basic life support. The first aid refresher framework was re-issued nationally in August 2023. It outlines the requirements for emergency first aid and first aid at work, emphasising the responsibility of Governors to always ensure adequate first aid cover. This is achieved by conducting a detailed local risk assessment to establish the number of trained first aiders at work (FAW) and emergency first aiders at work (EFAW) needed for each establishment.” Source location Response from HM Prison and Probation Service
Open published response
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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 Healthcare professionals, not officers, are responsible for assessing prisoners’ mental capacity when staff have concerns.
Verbatim wording from the response “Officers are not expected to assess a prisoner’s mental capacity; this responsibility lies with healthcare professionals. Where staff have concerns about a prisoner’s mental capacity, they are directed to seek healthcare input. Staff are instead required to act in accordance with policy, supported by appropriate de-escalation techniques and, to apply use-of-force measures only when strictly necessary and in a proportionate and sensitive manner.” Source location Response from HM Prison and Probation Service
Open published response
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.
×
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 HM Prison and Probation Service; 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 HM Prison and Probation Service; 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 HM Prison and Probation Service; 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 HM Prison and Probation Service; 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
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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 Share targeted illicitly brewed alcohol briefing materials with the local Drug Strategy Lead to support awareness, harm reduction and operational decision-making.
Verbatim wording from the response “In response to seasonal increases in IBA reported usage, the DAG issued a targeted briefing note outlining specific risks, indicators of IBA production, and guidance on effective operational responses. These materials have been shared with the Drug Strategy Lead here at HMP Guys Marsh to support local awareness-raising, harm reduction initiatives, and inform our decision-making.” Source location Response from HM Prison & Probation Service
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 focused searches to identify and safely remove illicitly brewed alcohol, then report and destroy items discovered.
Verbatim wording from the response “Searching operations continue with a specific focus on identifying and safely removing IBA, which is subsequently reported and destroyed by the Security Department when discovered.” Source location Response from HM Prison & Probation Service
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 Introduce a Local Operating Procedure for managing incidents involving prisoners found under the influence, including illicitly brewed alcohol.
Verbatim wording from the response “A comprehensive Local Operating Procedure (LOP) has been introduced, to guide staff in managing incidents involving prisoners found under the influence, including those affected by IBA.” Source location Response from HM Prison & Probation Service
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 Restrict access to commonly used brewing ingredients by removing waste-based items from the canteen list and limiting fruit and natural sugar-based products.
Verbatim wording from the response “In addition, preventative steps have been taken to limit the availability of ingredients commonly used in brewing IBA. Waste-based items have been removed from the canteen list, and fruit and natural sugar-based products have been restricted. These measures aim to reduce the opportunity for prisoners to produce IBA.” Source location Response from HM Prison & Probation Service
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 Ensure in-cell medication safes are available and fit for purpose where used.
Verbatim wording from the response “In addition, in cell medication safes are available and we have renewed our focus on ensuring these are available and fit-for-purpose where utilised.” Source location Response from HM Prison & Probation Service
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 Introduce a local operating procedure at HMP Guys Marsh for managing prisoners found under the influence, including those affected by illicitly brewed alcohol.
Verbatim wording from the response “Locally, HMP Guys Marsh has implemented a series of targeted local measures to mitigate the risks of IBA. A comprehensive Local Operating Procedure (LOP) has been introduced to guide staff in managing incidents involving prisoners found under the influence, including those affected by IBA. Searching operations continue with a specific focus on identifying and safely removing IBA, which must be reported and destroyed by the Security Department. To strengthen these efforts, the Dedicated Searching Team is deployed to support intelligence-led searches where IBA is a priority concern.” Source location Response from HM Prison and Probation Services
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 Develop and disseminate staff guidance and awareness materials on illicitly brewed alcohol, including the Drugs in Prison and Probation guide.
Verbatim wording from the response “Regarding the management of illicitly brewed alcohol, the Drug and Alcohol Group (DAG) in HMPPS has developed and disseminated a range of materials specifically focused on illicitly brewed alcohol (IBA). Notably, the Drugs in Prison and Probation (DiPP) guide provides comprehensive information for staff at all levels—from frontline officers to heads of function. It is designed to enhance understanding of substances, support structured discussions, raise awareness, and assist with induction processes for new staff.
Harm reduction support for alcohol use is growing across the prison estate, with mutual aid groups like Alcoholics Anonymous playing a key role. In addition, Incentivised Substance Free Living (ISFL) units are now available in 85 prisons, including at HMP Guys Marsh,” Source location Response from HM Prison and Probation Services
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 Provide targeted seasonal briefing materials on illicitly brewed alcohol risks, production indicators and operational responses to prison Drug Strategy Leads.
Verbatim wording from the response “offering a supportive environment for individuals to address both alcohol and drug-related issues. As part of wider awareness efforts, Prison Radio is being recommissioned to feature speakers with lived experience of alcohol-related harm, helping to highlight the impact of substance use and promote the support available.” Source location Response from HM Prison and Probation Services
Open published response
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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 NHS England and Oxleas NHS Foundation Trust are responsible for prisoners’ medication management, prescribing and decisions about medication held in possession.
Verbatim wording from the response “The handling of medication held in possession (IP) by prisoners and prescribing practices in prisons are the responsibility of NHS England. Here at HMP Guys Marsh, our commissioned partner is Oxleas NHS Foundation Trust.” Source location Response from HM Prison & Probation Service
Open published response
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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 Responsibility for prisoners’ in-possession medication and prescribing lies with NHS England under clinical assurance and national service specifications.
Verbatim wording from the response “The handling of medication held in possession (IP) by prisoners and prescribing practices in prisons are the responsibility of NHS England. The safe management of medication is governed by clinical assurance and national service specifications, which set out standards for prescribing, dispensing, and monitoring medication.” Source location Response from HM Prison and Probation Services
Open published response
25 Jul 2025 Michael Pugh · Prevention of Future Deaths report Kent and Medway
View report summary
Concerns raised 2 Failure to carry out and record ACCT observations at unpredictable times View source Inadequate training on the ACCT process View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Michael Pugh · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Michael Pugh was found dead in his prison cell on 29 June 2024 while subject to an ACCT. No observations were carried out between 07.22 and 09.57 on the day he was discovered, and the record was completed retrospectively; concerns also included new officers’ incomplete understanding of the ACCT observation and recording requirements.
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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out and record ACCT observations at unpredictable times
Wider context from the report “(1) The prison officers who gave evidence in relation to observations on 28th and 29th June 2024 were relatively new recruits, one having 3 months experience following POEL training and the other 1 month experience. Both officers gave evidence that following their POEL training their understanding of the ACCT process was incomplete; one stating “observations were explained but I didn’t have a fair idea what to do or how to undergo the process”, another stating “I didn’t understand the importance of observing a prisoner at unpredictable times. Even though I was told the observations should be hourly it was not explained to me how to stagger timing. I misunderstood what was required of me in recording the details when I recorded them as having happened at 13.00, 14.00, 15.00 and 16.00.
” 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Inadequate training on the ACCT process
Wider context from the report “(1) The prison officers who gave evidence in relation to observations on 28th and 29th June 2024 were relatively new recruits, one having 3 months experience following POEL training and the other 1 month experience. Both officers gave evidence that following their POEL training their understanding of the ACCT process was incomplete ; one stating “observations were explained but I didn’t have a fair idea what to do or how to undergo the process ”, another stating “I didn’t understand the importance of observing a prisoner at unpredictable times. Even though I was told the observations should be hourly it was not explained to me how to stagger timing. I misunderstood what was required of me in recording the details when I recorded them as having happened at 13.00, 14.00, 15.00 and 16.00.
” 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 Promote the Safety Learning Reference Library to new staff during induction and signpost it to all staff during the next national safety focus initiative.
Verbatim wording from the response “include examples of best practice for carrying out ACCT observations. Going forward HMP Swaleside will promote the Safety Learning Reference Library to new members of staff during their induction and, furthermore, will signpost the Safety Learning Reference Library to all staff during the HMPPS annual national safety focus initiative being held next month.” Source location Response from HM Prison & Probation Service
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 Provide role-specific ACCT training to staff undertaking key ACCT case-management roles, including assessors and case coordinators.
Verbatim wording from the response “Additionally, any member of staff who undertakes a key role relating to ACCT case management, for example ACCT assessors or case co-ordinators, receives training specific to these roles.” Source location Response from HM Prison & Probation Service
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 Maintain an online Safety Learning Reference Library with ACCT guidance, templates, training materials and observation-recording resources accessible to staff.
Verbatim wording from the response “In addition to the training HMPPS has an online Safety Learning Reference Library which holds various guidance, templates and training material, all of which are accessible to all staff via the HMPPS intranet. The library includes an area dedicated to ACCT where staff can access a ‘Recording Observations’ video guide as well as a written guide, both of which” Source location Response from HM Prison & Probation Service
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 Provide all new prison officers with a full day of suicide and self-harm prevention training, including ACCT procedures and observation recording requirements.
Verbatim wording from the response “All new members of staff receive a full day of training on suicide and self-harm prevention during their POELT training. This includes training on the ACCT process and the appropriate timings and intervals of when ACCT observations need to be carried out and recorded. Following completion of POELT training, new entry officers have a two week local induction before ‘going live’ and becoming fully operational. Part of this local induction programme at Swaleside includes ACCT upskilling and a session based on completion of ACCT documents and recording of ACCT observations. The local training team keep a record of these sessions. Any further training needs for staff would be identified and delivered locally.” Source location Response from HM Prison & Probation Service
Open published response
18 Jul 2025 Patryk Gladysz · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 8 Out-of-date First Aid refresher training for healthcare staff View source Failure of prison and healthcare staff to share knowledge about people presenting with serious and enduring mental health illness View source Inconsistent understanding among prison and healthcare staff of healthcare access to NOMIS View source Ongoing challenges in prison officer checks of roll calls and ACCT observations View source Insufficient Mental Health in-reach team staffing for timely meaningful and quality mental health assessments View source Deactivation of healthcare staff NOMIS accounts due to lack of use View source Lack of prison staff knowledge of the heightened risk of foreign nationals in custody View source Staffing levels diluting key worker scheme requirements View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Patryk Gladysz · 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
Patryk Gladysz, who had schizophrenia and was detained at HMP Wandsworth, was found in his cell with a ligature around his neck on 5 January 2024 and died at St George’s Hospital. The inquest concluded that he had hung himself with a ligature, with his intentions unknown. Concerns included delays and staffing pressures affecting mental health assessments, inadequate communication between prison and healthcare staff, gaps in knowledge of his history and risks, and shortcomings in prison monitoring and training.
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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Out-of-date First Aid refresher training for healthcare staff
Wider context from the report “(6) First Aid refresher training is not up to date for all healthcare staff .
” 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure of prison and healthcare staff to share knowledge about people presenting with serious and enduring mental health illness
Wider context from the report “(4) Communication between prison and healthcare staff regarding: (a) knowledge sharing of those presenting with a serious and enduring mental health illness, such as schizophrenia ; (b) inconsistent understanding of healthcare access to the NOMIS by both prison and healthcare staff; and (c) de-activation of NOMIS accounts for healthcare staff due to lack of use – 21 healthcare accounts were de-activated notwithstanding an increase in available terminals.
” 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Inconsistent understanding among prison and healthcare staff of healthcare access to NOMIS
Wider context from the report “(4) Communication between prison and healthcare staff regarding: (a) knowledge sharing of those presenting with a serious and enduring mental health illness, such as schizophrenia; (b) inconsistent understanding of healthcare access to the NOMIS by both prison and healthcare staff ; and (c) de-activation of NOMIS accounts for healthcare staff due to lack of use – 21 healthcare accounts were de-activated notwithstanding an increase in available terminals.
” 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Ongoing challenges in prison officer checks of roll calls and ACCT observations
Wider context from the report “(5) Prison officer checks of roll calls/ACCT observations - recent audit by HMP Wandsworth suggests on-going challenges .
” 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Insufficient Mental Health in-reach team staffing for timely meaningful and quality mental health assessments
Wider context from the report “(1) Staffing within the Mental Health in-reach team impacting the timely undertaking of meaningful and quality mental health assessments .
” 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Deactivation of healthcare staff NOMIS accounts due to lack of use
Wider context from the report “(4) Communication between prison and healthcare staff regarding: (a) knowledge sharing of those presenting with a serious and enduring mental health illness, such as schizophrenia; (b) inconsistent understanding of healthcare access to the NOMIS by both prison and healthcare staff; and (c) de-activation of NOMIS accounts for healthcare staff due to lack of use – 21 healthcare accounts were de-activated notwithstanding an increase in available terminals .
” 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Lack of prison staff knowledge of the heightened risk of foreign nationals in custody
Wider context from the report “(3) Knowledge of prison staff of the heightened risk of foreign nationals in custody , despite a higher proportion of foreign nationals being detained at HMP Wandsworth.
” 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Staffing levels diluting key worker scheme requirements
Wider context from the report “(2) Staffing within HMP Wandsworth resulting in a dilution to the requirements for the key worker scheme .
” 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 Assign a Custodial Manager to oversee keyworker allocation, training and data, with weekly management review.
Verbatim wording from the response “HMP Wandsworth now has an assigned Custodial Manager to provide robust oversight of allocation, training and data of the keyworker scheme. The data is shared weekly during the” Source location Response from HM Prison and Probation Service
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 Increase prison officer staffing through recruitment, bringing HMP Wandsworth above its target staffing level.
Verbatim wording from the response “I have received assurance from the Governor of HMP Wandsworth that there has been improvement in staffing figures and that there is evidence of a higher retention rate as the months progress. There has been a recent recruitment intake which has added to the existing staffing group and has elevated HMP Wandsworth’s prison officer levels to above the target staffing figure.” Source location Response from HM Prison and Probation Service
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 Automatically assign keyworkers to higher-risk prisoners to provide support at the earliest opportunity.
Verbatim wording from the response “morning meeting to provide consistent management oversight. Additionally, prisoners who are deemed to be higher risk are automatically assigned a keyworker to ensure they are provided with adequate support at the earliest opportunity. The combination of improvement in staffing and the allocation of managerial oversight to the keyworker scheme will contribute to an improvement in its delivery.” Source location Response from HM Prison and Probation Service
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 Implement monthly assurance checks comparing documented ACCT observations with CCTV footage and take action on non-compliance.
Verbatim wording from the response “Prison staff have received briefings with regards to their responsibilities during roll checks, including the need for timely completion and the requirement for a response to be gained from the prisoner to ensure their wellbeing. This has resulted in an improvement in documented roll check timings. The Governor of HMP Wandsworth has now also implemented a monthly assurance check, which cross references documented ACCT observations against CCTV footage. Appropriate action is taken against any member of staff who does not complete these checks in line with national policy.” Source location Response from HM Prison and Probation Service
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 Brief prison staff on roll-check responsibilities, including timely completion and obtaining a wellbeing response from each prisoner.
Verbatim wording from the response “Prison staff have received briefings with regards to their responsibilities during roll checks, including the need for timely completion and the requirement for a response to be gained from the prisoner to ensure their wellbeing. This has resulted in an improvement in documented roll check timings. The Governor of HMP Wandsworth has now also implemented a monthly assurance check, which cross references documented ACCT observations against CCTV footage. Appropriate action is taken against any member of staff who does not complete these checks in line with national policy.” Source location Response from HM Prison and Probation Service
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 Train and brief prison staff to recognise heightened self-harm and suicide risks among foreign national offenders.
Verbatim wording from the response “HMP Wandsworth are working collaboratively with Catch 22 to improve the support given to FNOs whilst in custody. This includes facilitating a bespoke induction plan and translating all information available to prisoners into the ten most common languages to ensure all FNOs have equal access. Prison staff are made aware during their initial ACCT training of the groups of prisoners who are at heightened risk of self-harm and suicide, such as FNOs. This includes recognising risks in a prisoner’s history and their presentation, rather than relying solely on verbal information received from the individual. This information is now also regularly communicated to prison staff during briefings.” Source location Response from HM Prison and Probation Service
Open published response
10 Jul 2025 Gavin James WHEALE · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 2 Failure to provide equivalent monitoring for prisoners after handover from constant supervision View source Lack of clear staff guidance for managing internally secreted items that are removed and ingested without their previous packaging View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Gavin James WHEALE · 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
Gavin James Wheale was found unresponsive in a care and separation unit cell at HMP Birmingham on 8 August 2024 and was pronounced dead shortly afterwards. The medical cause of death was mixed drug interactions involving morphine, cocaine and diazepam. Concerns included unclear guidance for staff where a previously concealed item was allegedly ingested, and reduced monitoring after handover from transport and police custody to the prison.
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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to provide equivalent monitoring for prisoners after handover from constant supervision
Wider context from the report “2. Evidence was heard from WMP and GEOAmey staff dealing with their required procedures where a person in their custody, in this instance Mr Wheale, was known or suspected of concealing items; both organisations required constant supervision and handcuffing. My concern is that upon handover to HMP Birmingham prisoners who have previously been under constant supervision, with their movement restricted, enter a regime with no equivalent levels of monitoring rendering HMP Birmingham unable to fully discharge their duty of care to that prisoner .
” 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Lack of clear staff guidance for managing internally secreted items that are removed and ingested without their previous packaging
Wider context from the report “1. At the time Mr Wheale resided in HMP Birmingham, HMP Birmingham Secreted Item Policy (January 2020) was in force. An updated policy was issued after Mr Wheale’s death (dated Aug 2024). Both versions of the policy accept that ‘There is a clear risk to a prisoner’s health when an item is secreted internally’. My concern is that focus of the policy is the prevention of contraband entering the prison system and therefore it presupposes the outcome of the secreted item(s) being surrendered or disposed of by the prisoner. It does not provide clear guidance to staff on a situation, as with Mr Wheale, where an item previously concealed is then claimed to have been (or indeed a situation where it was witnessed to have been) removed and ingested without its previous packaging.
” 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 Issue staff guidance requiring fully documented risk assessments and recorded risk-management actions for prisoners entering HMP Birmingham under constant supervision.
Verbatim wording from the response “You also raise a concern regarding the management of prisoners who enter the prison on high levels of monitoring. In response to this, HMP Birmingham will be issuing guidance to staff to ensure that a fully documented risk assessment is completed for any prisoner entering the establishment under constant supervision, whether due to secreted items or other reasons - to ensure that the individual is managed effectively and safely, clearly documenting the actions to be taken to manage any associated risks.” Source location Response from HM Prison and Probabtion Service
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 Update HMP Birmingham’s Secreted Items Policy with staff guidance for suspected prisoner ingestion, including healthcare notification, observations and consideration of suicide and self-harm procedures.
Verbatim wording from the response “The first concern you raise relates to HMP Birmingham’s Secreted Items Policy and its focus on preventing contraband from entering the prison system. I can confirm that following the inquest the prison has committed to updating the local policy to include clear guidance for staff on the action they need to take where it is suspected that a prisoner has ingested an item. The guidance will cover steps such as notifying healthcare, initiating appropriate observations, and considering whether suicide and self-harm procedures should be opened. Additionally, the West Midlands group Safety Lead will ensure that consistent guidance is implemented across all establishments within their regional area.” Source location Response from HM Prison and Probabtion Service
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 Implement consistent suspected-ingestion guidance across establishments in the West Midlands region.
Verbatim wording from the response “The first concern you raise relates to HMP Birmingham’s Secreted Items Policy and its focus on preventing contraband from entering the prison system. I can confirm that following the inquest the prison has committed to updating the local policy to include clear guidance for staff on the action they need to take where it is suspected that a prisoner has ingested an item. The guidance will cover steps such as notifying healthcare, initiating appropriate observations, and considering whether suicide and self-harm procedures should be opened. Additionally, the West Midlands group Safety Lead will ensure that consistent guidance is implemented across all establishments within their regional area.” Source location Response from HM Prison and Probabtion Service
Open published response
4 Jul 2025 George EMMETT · Prevention of Future Deaths report Buckinghamshire
View report summary
Concerns raised 1 Failure of operational staff to follow local medical emergency response protocols View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
George EMMETT · 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
George Emmett died after taking synthetic cannabinoid in G-Wing at HMP Aylesbury on 25 May 2023. The report raises a continuing concern that emergency responses involving prisoners may be compromised if staff do not follow the HMPPS Medical Emergency Response Codes policy, including promptly summoning an ambulance and calling a Code Blue.
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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure of operational staff to follow local medical emergency response protocols
Wider context from the report “Evidence at the inquest demonstrated a Code Blue should be called over the radio from the cell location where a situation such as that in which George was found has arisen.
The evidence of OSG ████████ did not appear to demonstrate familiarity with the processes set out in this policy at the time of George's death, nor any greater familiarity during evidence given, some two years after George's death.
It is understood OSG ████████ holds a similar role at HMP Woodhill.
There is a continuing concern that optimum reaction to an emergency situation involving the health of a prisoner may be compromised if OSG ████████ were to react in a manner which was not in accordance with any local protocols reflective of the HMPPS Medical Emergency Response Codes policy.
The circumstances anticipated by this policy include situations where a prisoner's death may be prevented with appropriate application of an emergency response.
” 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 Reissue six-monthly Governor’s Notices and conduct regular staff briefings to reinforce medical emergency response procedures and emergency-code use.
Verbatim wording from the response “HMP Aylesbury continue to take steps to ensure that staff can confidently take effective action in the event of a medical emergency and in particular in the calling of emergency codes. A Governor’s Notice is reissued every six months reminding staff of the emergency response protocols to embed this awareness as much as possible. Additionally, full staff briefings are regularly used to reinforce procedures.” Source location 2025-0345 Response from HM Prison & Probation Service
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 Issue portable Code Red/Code Blue prompt cards and display posters as accessible reminders of emergency-code procedures.
Verbatim wording from the response “Staff have also been issued with quick reference Code Red/Code Blue prompt cards which can be carried on the person and act as an immediately accessible reminder of the circumstances in which a Code Red or Code Blue should be called. This information is also provided on posters as an additional visual aid.” Source location 2025-0345 Response from HM Prison & Probation Service
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 Brief the referenced Operational Support Grade individually on night procedures and the Local Security Strategy.
Verbatim wording from the response “HMP Woodhill have advised me that the Operational Support Grade (OSG) who you reference in your report has now received one-to-one briefing on night procedures and the Local Security Strategy. As a further training aid and audit tool, a sign-off sheet was introduced whereby all routine expectations of a night OSG had been listed, such as the use of the radio and the use of emergency codes, the expectation being that this record be discussed by the OSG and the Night Orderly Officer and signed to confirm understanding. The support of the establishment care team has also been offered to the OSG.” Source location 2025-0345 Response from HM Prison & Probation Service
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 Issue a staff information notice, distribute Code Red/Code Blue prompt cards and remind control-room staff to follow emergency-services calling protocols.
Verbatim wording from the response “On 20 June 2025 a staff information notice was issued to all HMP Woodhill staff reminding them of the policy around medical emergency response procedures and the national guidance on the appropriate use of calling a Code Red or Code Blue during an emergency. Additionally, the establishment have also issued take-along, quick reference, Code Red/Code Blue prompt cards to staff, and control room staff have been reminded of the importance of following the national protocol for calling emergency services for all incidents where a Code Red or Code Blue has been called.” Source location 2025-0345 Response from HM Prison & Probation Service
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 Use sign-off sheets for night Operational Support Grades to confirm understanding of routine duties, radio use and emergency-code procedures.
Verbatim wording from the response “HMP Woodhill have advised me that the Operational Support Grade (OSG) who you reference in your report has now received one-to-one briefing on night procedures and the Local Security Strategy. As a further training aid and audit tool, a sign-off sheet was introduced whereby all routine expectations of a night OSG had been listed, such as the use of the radio and the use of emergency codes, the expectation being that this record be discussed by the OSG and the Night Orderly Officer and signed to confirm understanding. The support of the establishment care team has also been offered to the OSG.” Source location 2025-0345 Response from HM Prison & Probation Service
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 Use mentoring, induction competency checks and radio communication training to train and test newly appointed officers on radios and emergency response procedures.
Verbatim wording from the response “The prison has a colleague mentor programme whereby newly trained officers are assigned a mentor to provide support, advice and guidance throughout their initial training and full probation period. An induction ‘passport’ is used to provide assurance that the individual is competent in their role before they become fully operational. The mentors play an active role in training and testing new staff, this includes the use of radios and emergency” Source location 2025-0345 Response from HM Prison & Probation Service
Open published response
Concerns raised 2 Lack of diabetes training and awareness among Prison Service staff View source Unavailability of prison healthcare outside limited operating hours View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Colin David Lovett · 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 29 October 2022, Colin David Lovett was found collapsed and unresponsive in his room at HMP The Verne. The report raised concerns about prison staff’s lack of awareness and training regarding diabetes, limited out-of-hours healthcare access, and the support available to prisoners with insulin-dependent diabetes. It also identified concerns about telephone-call monitoring, access to medication, and the adequacy of risk management and support at HMP The Verne.
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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Lack of diabetes training and awareness among Prison Service staff
Wider context from the report “(1) Evidence was provided by Prison Service staff during the Inquest that they have never received training about diabetes and there is a lack of understanding , and national guidance for Prison Service staff relating to the symptoms of a hypo glycaemic or hyper glycaemic attack, which can be fatal.
(2) The healthcare department at HMP The Verne is only operated between 7.30am and 6pm daily and is not therefore available 24 hours a day. Outside of these operational times, access to healthcare would be via 111 or 999 which could cause delay in action being taken to resolve a hypo glycaemic or hyper glycaemic attack. This will be the position in other prisons nationally.
(3) Whilst insulin dependent diabetics are likely to be experts in their own care, some prisoners may have poorly managed diabetes and require support which could be at any time.
(4) It is acknowledged that there is a balance to be stuck with training non-medical individuals in diagnosing medical symptoms, which could lead to miss diagnosis, and ensuring care is provided without delay, however the Head of Healthcare at HMP The Verne stated that there would be benefit in providing an awareness to Prison Service staff of the impact on prisoners of long term conditions such as diabetes .
(5) Several members of Prison Service staff gave evidence at the Inquest and only one, who had personal experience through a family member, had an understanding of diabetes and the impact it can have upon an individual, including the symptoms of a hypo glycaemic or hyper glycaemic attack .
(6) Prisoners are dependent upon support provided by Prison Staff. I am concerned that the lack of awareness of the needs of prisoners with insulin dependent diabetes amongst Prison Service staff who provide care to prisoners at times when healthcare staff are not on site , 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Unavailability of prison healthcare outside limited operating hours
Wider context from the report “(2) The healthcare department at HMP The Verne is only operated between 7.30am and 6pm daily and is not therefore available 24 hours a day . Outside of these operational times, access to healthcare would be via 111 or 999 which could cause delay in action being taken to resolve a hypo glycaemic or hyper glycaemic attack . This will be the position in other prisons nationally.
(3) Whilst insulin dependent diabetics are likely to be experts in their own care, some prisoners may have poorly managed diabetes and require support which could be at any time .
” 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 Discussed local diabetes awareness needs with the healthcare provider at HMP The Verne.
Verbatim wording from the response “This is precisely what has now happened at The Verne where following discussion with the Governor, the healthcare provider has provided a diabetes awareness and guidance document which has been disseminated to all staff.” Source location Response from HMPPS
Open published response
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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 Requiring all operational prison staff to undertake diabetes-specific training is unnecessary because training time is prioritised for higher-priority or broadly applicable topics.
Verbatim wording from the response “I understand your concern to ensure that prisoners with diabetes receive high quality care. However, I do not believe that it is necessary or appropriate to require all operational prison staff to undertake specific training or awareness sessions relating to diabetes. Training time is limited and there are many other topics that are of higher priority and/or have more general application. Instead, where a healthcare provider identifies a need for prison officers to have increased awareness of diabetes (or any other particular medical condition) locally, they are able to raise this with the Governor and consideration can then be given to developing local awareness sessions, which can be delivered by healthcare staff as deemed necessary.” Source location Response from HMPPS
Open published response
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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 NHS England is responsible for commissioning prison healthcare services and will address healthcare provider operating hours.
Verbatim wording from the response “Following evidence heard at the inquest, you have raised concerns regarding diabetes awareness training among prison staff and emphasised the importance of this in the light of the restricted operating hours of the healthcare provider at HMP The Verne. My response will address the point about staff awareness training, and I understand that NHS England will send a separate response addressing the issue of healthcare operating hours, as they have responsibility for the commissioning of healthcare services within prisons.” Source location Response from HMPPS
Open published response
2 May 2025 Sarah Frances BOYLE · Prevention of Future Deaths report Cheshire
View report summary
Concerns raised 8 Failure to respond reliably to expressions of self harm or suicidality View source ACCT observations failing to provide therapeutic support View source Insufficient mental health input for women not case loaded to the mental health team View source Delays in transferring women requiring mental health inpatient treatment View source Insufficient staffing capacity to complete ACCT checks and documentation View source Inconsistent completion of the ACCT process View source Insufficient mental health team capacity for women awaiting assessment or inpatient beds View source Insufficient mental health training and time for prison officers conducting meaningful ACCT conversations View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Sarah Frances BOYLE · 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
Sarah Boyle was detained at HMP Styal and was monitored under the ACCT process after expressing thoughts of self-harm or suicide and making several ligature attempts. On 14 July 2024, she was found with a ligature around her neck, suffered irreversible brain damage, and died in hospital on 20 July 2024. The report raises concerns that the ACCT process at HMP Styal was not working effectively, citing high levels of self-harm, complex mental-health needs, understaffing, missed checks, and inconsistent completion of the process.
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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to respond reliably to expressions of self harm or suicidality
Wider context from the report “I am concerned that the ACCT process or system currently in place designed to keep women safe at HMP Styal is not working effectively, and that there is a risk of future deaths if the process is not reconsidered or amended to better suit the needs of this prison. The ACCT process allows for observations of a woman who is at risk of self harm or suicide to keep her safe, but these are not a therapeutic observation and are essentially a check to ensure that the woman is alive and not actively self harming. Mental health input, if a woman is not case loaded to the mental health team, can be minimal, limited to attendance at a case review at best, and this does not allow for an opportunity to improve the woman’s mental health, to reduce the risk of future suicide attempts. Care plans allowing for meaningful activity assist but their effectiveness is limited alongside the prison regime. I acknowledge that prison is not intended to be a therapeutic environment but given the number of women with mental health needs, I am concerned that the current environment or processes will give rise to a risk of future deaths.
My concerns are based on the following points which I heard in evidence:
• HMP Styal is a women’s prison with a high number of self inflicted deaths, compared to the rest of the female estate. I am told by the prison ombudsman that they have the highest number of deaths between January 2022 and January 2025, accounting on my calculation for almost half of the total deaths in the female estate across England. I am aware that there has been one self inflicted death this year to date, and we are only 4 months in;
• I heard evidence from the Head of Safer Prisons and Equality at HMP Styal and the Service Manager for Greater Manchester Mental Health NHS FT, who provide the mental health care in the prison, that the mental health needs of the women detained at Styal are high and can be complex. The latter explained that they receive women from court who have been sent to prison following a criminal act but are essentially awaiting assessment to see whether they should be detained in prison, or in a mental health hospital. The mental health team is then expected to care for the woman for the prolonged period of assessment and awaiting a bed if deemed necessary, something they are not set up to do. It was the view of this witness that Styal was receiving a number of prisoners who are complex and risky and require treatment in a mental health hospital. The process for transfer then takes time and is an additional pressure on the team. The powers of a mental health team in prison are far more restricted, for example, they cannot force medication if needed, and it is reliant on the engagement of prisoners which they frequently do not get. The mental health Trust confirmed that in 2025 to date (29.4.25), 11 prisoners have been referred for a Mental Health Act assessment and of these 11, 8 were accepted for transfer and treatment in a mental health inpatient setting;
• It was the evidence of the Head of Safer Prisons and Equality that they also receive women who are there for a ‘warrant of concern’. A ‘warrant of concern’ is where a woman attends court and is not sentenced at that point but remanded into prison custody due to the Judge having concerns that they are not safe to be released into the community and where it is perceived that they will be safer in custody. This is usually where there are concerns around the woman’s mental health and/or risk to self. This adds pressure on an already stretched resource level in prisons as more resources are generally required to manage such complex individuals; Prison data suggests that HMP Styal have received 7 women on ‘warrants of concern’ since November 2024 to date (April 2025);
• I heard from one witness that a ‘good day’ on one side of the wing would just be one incident of self harm, but there would be frequently multiple incidents;
• The number of number of self harm incidents and ACCT documents open appears to have hardened the prison team to expressions of self harm etc. I heard comments throughout the inquest such as “If I opened an ACCT on every woman who said she was suicidal we’d have loads open”, and “2 incidents of self harm in a morning for one prisoner might seem like a lot but it’s not in the context of Styal”. This may lead to key cases being missed ;
• The number of ACCTs open within the prison can be high given the mental health need. I have heard evidence from a number of witnesses as to the pressures that the ACCT process places on staff, primarily due to the high number compared to staffing numbers. The severity of this varied in evidence depending seemingly on whether the member of staff was still with the prison service or had left. The clear consensus however was that the carrying out of ACCT checks, meaningful conversations and documentation of this was difficult whilst also trying to manage the day to day regime. It was accepted by the Head of Safer Prisons and Equality at HMP Styal that the officer on duty on the day of Sarah’s death would have been responsible for 48 checks an hour, and that was not unusual. Evidence from one witness, who has since left the prison, was that as a result of the number of checks required, and the limited resource to do them, checks were frequently missed;
• Meaningful conversations, designed to find out how the person is feeling and check in with them, are being carried out by prison officers with very limited mental health training, with very limited time resource to do this. Mental health training is not mandatory for the officers and can be overlooked due to more pressing, mandatory training.
The jury findings record “Understaffing and a high number of ACCT documents at HMP Styal led to inconsistencies with how staff completed each part of the ACCT process”.
In addition to the evidence heard from the witnesses, I am mindful of the report of HM Chief Inspector of Prisons (Time to care: what helps women cope in prison February 2025) which notes that the rate of self harm among women in prison is now 8.5 times higher than in men’s jails, and highlights a number of issues which continue to this, which have been reflected in this inquest.
” 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation ACCT observations failing to provide therapeutic support
Wider context from the report “I am concerned that the ACCT process or system currently in place designed to keep women safe at HMP Styal is not working effectively, and that there is a risk of future deaths if the process is not reconsidered or amended to better suit the needs of this prison. The ACCT process allows for observations of a woman who is at risk of self harm or suicide to keep her safe, but these are not a therapeutic observation and are essentially a check to ensure that the woman is alive and not actively self harming . Mental health input, if a woman is not case loaded to the mental health team, can be minimal, limited to attendance at a case review at best, and this does not allow for an opportunity to improve the woman’s mental health, to reduce the risk of future suicide attempts. Care plans allowing for meaningful activity assist but their effectiveness is limited alongside the prison regime. I acknowledge that prison is not intended to be a therapeutic environment but given the number of women with mental health needs, I am concerned that the current environment or processes will give rise to a risk of future deaths.
My concerns are based on the following points which I heard in evidence:
• HMP Styal is a women’s prison with a high number of self inflicted deaths, compared to the rest of the female estate. I am told by the prison ombudsman that they have the highest number of deaths between January 2022 and January 2025, accounting on my calculation for almost half of the total deaths in the female estate across England. I am aware that there has been one self inflicted death this year to date, and we are only 4 months in;
• I heard evidence from the Head of Safer Prisons and Equality at HMP Styal and the Service Manager for Greater Manchester Mental Health NHS FT, who provide the mental health care in the prison, that the mental health needs of the women detained at Styal are high and can be complex. The latter explained that they receive women from court who have been sent to prison following a criminal act but are essentially awaiting assessment to see whether they should be detained in prison, or in a mental health hospital. The mental health team is then expected to care for the woman for the prolonged period of assessment and awaiting a bed if deemed necessary, something they are not set up to do. It was the view of this witness that Styal was receiving a number of prisoners who are complex and risky and require treatment in a mental health hospital. The process for transfer then takes time and is an additional pressure on the team. The powers of a mental health team in prison are far more restricted, for example, they cannot force medication if needed, and it is reliant on the engagement of prisoners which they frequently do not get. The mental health Trust confirmed that in 2025 to date (29.4.25), 11 prisoners have been referred for a Mental Health Act assessment and of these 11, 8 were accepted for transfer and treatment in a mental health inpatient setting;
• It was the evidence of the Head of Safer Prisons and Equality that they also receive women who are there for a ‘warrant of concern’. A ‘warrant of concern’ is where a woman attends court and is not sentenced at that point but remanded into prison custody due to the Judge having concerns that they are not safe to be released into the community and where it is perceived that they will be safer in custody. This is usually where there are concerns around the woman’s mental health and/or risk to self. This adds pressure on an already stretched resource level in prisons as more resources are generally required to manage such complex individuals; Prison data suggests that HMP Styal have received 7 women on ‘warrants of concern’ since November 2024 to date (April 2025);
• I heard from one witness that a ‘good day’ on one side of the wing would just be one incident of self harm, but there would be frequently multiple incidents;
• The number of number of self harm incidents and ACCT documents open appears to have hardened the prison team to expressions of self harm etc. I heard comments throughout the inquest such as “If I opened an ACCT on every woman who said she was suicidal we’d have loads open”, and “2 incidents of self harm in a morning for one prisoner might seem like a lot but it’s not in the context of Styal”. This may lead to key cases being missed;
• The number of ACCTs open within the prison can be high given the mental health need. I have heard evidence from a number of witnesses as to the pressures that the ACCT process places on staff, primarily due to the high number compared to staffing numbers. The severity of this varied in evidence depending seemingly on whether the member of staff was still with the prison service or had left. The clear consensus however was that the carrying out of ACCT checks, meaningful conversations and documentation of this was difficult whilst also trying to manage the day to day regime. It was accepted by the Head of Safer Prisons and Equality at HMP Styal that the officer on duty on the day of Sarah’s death would have been responsible for 48 checks an hour, and that was not unusual. Evidence from one witness, who has since left the prison, was that as a result of the number of checks required, and the limited resource to do them, checks were frequently missed;
• Meaningful conversations, designed to find out how the person is feeling and check in with them, are being carried out by prison officers with very limited mental health training, with very limited time resource to do this. Mental health training is not mandatory for the officers and can be overlooked due to more pressing, mandatory training.
The jury findings record “Understaffing and a high number of ACCT documents at HMP Styal led to inconsistencies with how staff completed each part of the ACCT process”.
In addition to the evidence heard from the witnesses, I am mindful of the report of HM Chief Inspector of Prisons (Time to care: what helps women cope in prison February 2025) which notes that the rate of self harm among women in prison is now 8.5 times higher than in men’s jails, and highlights a number of issues which continue to this, which have been reflected in this inquest.
” 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Insufficient mental health input for women not case loaded to the mental health team
Wider context from the report “I am concerned that the ACCT process or system currently in place designed to keep women safe at HMP Styal is not working effectively, and that there is a risk of future deaths if the process is not reconsidered or amended to better suit the needs of this prison. The ACCT process allows for observations of a woman who is at risk of self harm or suicide to keep her safe, but these are not a therapeutic observation and are essentially a check to ensure that the woman is alive and not actively self harming. Mental health input, if a woman is not case loaded to the mental health team, can be minimal, limited to attendance at a case review at best , and this does not allow for an opportunity to improve the woman’s mental health, to reduce the risk of future suicide attempts. Care plans allowing for meaningful activity assist but their effectiveness is limited alongside the prison regime. I acknowledge that prison is not intended to be a therapeutic environment but given the number of women with mental health needs, I am concerned that the current environment or processes will give rise to a risk of future deaths.
My concerns are based on the following points which I heard in evidence:
• HMP Styal is a women’s prison with a high number of self inflicted deaths, compared to the rest of the female estate. I am told by the prison ombudsman that they have the highest number of deaths between January 2022 and January 2025, accounting on my calculation for almost half of the total deaths in the female estate across England. I am aware that there has been one self inflicted death this year to date, and we are only 4 months in;
• I heard evidence from the Head of Safer Prisons and Equality at HMP Styal and the Service Manager for Greater Manchester Mental Health NHS FT, who provide the mental health care in the prison, that the mental health needs of the women detained at Styal are high and can be complex. The latter explained that they receive women from court who have been sent to prison following a criminal act but are essentially awaiting assessment to see whether they should be detained in prison, or in a mental health hospital. The mental health team is then expected to care for the woman for the prolonged period of assessment and awaiting a bed if deemed necessary, something they are not set up to do. It was the view of this witness that Styal was receiving a number of prisoners who are complex and risky and require treatment in a mental health hospital. The process for transfer then takes time and is an additional pressure on the team. The powers of a mental health team in prison are far more restricted, for example, they cannot force medication if needed, and it is reliant on the engagement of prisoners which they frequently do not get. The mental health Trust confirmed that in 2025 to date (29.4.25), 11 prisoners have been referred for a Mental Health Act assessment and of these 11, 8 were accepted for transfer and treatment in a mental health inpatient setting;
• It was the evidence of the Head of Safer Prisons and Equality that they also receive women who are there for a ‘warrant of concern’. A ‘warrant of concern’ is where a woman attends court and is not sentenced at that point but remanded into prison custody due to the Judge having concerns that they are not safe to be released into the community and where it is perceived that they will be safer in custody. This is usually where there are concerns around the woman’s mental health and/or risk to self. This adds pressure on an already stretched resource level in prisons as more resources are generally required to manage such complex individuals; Prison data suggests that HMP Styal have received 7 women on ‘warrants of concern’ since November 2024 to date (April 2025);
• I heard from one witness that a ‘good day’ on one side of the wing would just be one incident of self harm, but there would be frequently multiple incidents;
• The number of number of self harm incidents and ACCT documents open appears to have hardened the prison team to expressions of self harm etc. I heard comments throughout the inquest such as “If I opened an ACCT on every woman who said she was suicidal we’d have loads open”, and “2 incidents of self harm in a morning for one prisoner might seem like a lot but it’s not in the context of Styal”. This may lead to key cases being missed;
• The number of ACCTs open within the prison can be high given the mental health need. I have heard evidence from a number of witnesses as to the pressures that the ACCT process places on staff, primarily due to the high number compared to staffing numbers. The severity of this varied in evidence depending seemingly on whether the member of staff was still with the prison service or had left. The clear consensus however was that the carrying out of ACCT checks, meaningful conversations and documentation of this was difficult whilst also trying to manage the day to day regime. It was accepted by the Head of Safer Prisons and Equality at HMP Styal that the officer on duty on the day of Sarah’s death would have been responsible for 48 checks an hour, and that was not unusual. Evidence from one witness, who has since left the prison, was that as a result of the number of checks required, and the limited resource to do them, checks were frequently missed;
• Meaningful conversations, designed to find out how the person is feeling and check in with them, are being carried out by prison officers with very limited mental health training, with very limited time resource to do this. Mental health training is not mandatory for the officers and can be overlooked due to more pressing, mandatory training.
The jury findings record “Understaffing and a high number of ACCT documents at HMP Styal led to inconsistencies with how staff completed each part of the ACCT process”.
In addition to the evidence heard from the witnesses, I am mindful of the report of HM Chief Inspector of Prisons (Time to care: what helps women cope in prison February 2025) which notes that the rate of self harm among women in prison is now 8.5 times higher than in men’s jails, and highlights a number of issues which continue to this, which have been reflected in this inquest.
” 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Delays in transferring women requiring mental health inpatient treatment
Wider context from the report “I am concerned that the ACCT process or system currently in place designed to keep women safe at HMP Styal is not working effectively, and that there is a risk of future deaths if the process is not reconsidered or amended to better suit the needs of this prison. The ACCT process allows for observations of a woman who is at risk of self harm or suicide to keep her safe, but these are not a therapeutic observation and are essentially a check to ensure that the woman is alive and not actively self harming. Mental health input, if a woman is not case loaded to the mental health team, can be minimal, limited to attendance at a case review at best, and this does not allow for an opportunity to improve the woman’s mental health, to reduce the risk of future suicide attempts. Care plans allowing for meaningful activity assist but their effectiveness is limited alongside the prison regime. I acknowledge that prison is not intended to be a therapeutic environment but given the number of women with mental health needs, I am concerned that the current environment or processes will give rise to a risk of future deaths.
My concerns are based on the following points which I heard in evidence:
• HMP Styal is a women’s prison with a high number of self inflicted deaths, compared to the rest of the female estate. I am told by the prison ombudsman that they have the highest number of deaths between January 2022 and January 2025, accounting on my calculation for almost half of the total deaths in the female estate across England. I am aware that there has been one self inflicted death this year to date, and we are only 4 months in;
• I heard evidence from the Head of Safer Prisons and Equality at HMP Styal and the Service Manager for Greater Manchester Mental Health NHS FT, who provide the mental health care in the prison, that the mental health needs of the women detained at Styal are high and can be complex. The latter explained that they receive women from court who have been sent to prison following a criminal act but are essentially awaiting assessment to see whether they should be detained in prison, or in a mental health hospital. The mental health team is then expected to care for the woman for the prolonged period of assessment and awaiting a bed if deemed necessary, something they are not set up to do. It was the view of this witness that Styal was receiving a number of prisoners who are complex and risky and require treatment in a mental health hospital. The process for transfer then takes time and is an additional pressure on the team . The powers of a mental health team in prison are far more restricted, for example, they cannot force medication if needed, and it is reliant on the engagement of prisoners which they frequently do not get. The mental health Trust confirmed that in 2025 to date (29.4.25), 11 prisoners have been referred for a Mental Health Act assessment and of these 11, 8 were accepted for transfer and treatment in a mental health inpatient setting;
• It was the evidence of the Head of Safer Prisons and Equality that they also receive women who are there for a ‘warrant of concern’. A ‘warrant of concern’ is where a woman attends court and is not sentenced at that point but remanded into prison custody due to the Judge having concerns that they are not safe to be released into the community and where it is perceived that they will be safer in custody. This is usually where there are concerns around the woman’s mental health and/or risk to self. This adds pressure on an already stretched resource level in prisons as more resources are generally required to manage such complex individuals; Prison data suggests that HMP Styal have received 7 women on ‘warrants of concern’ since November 2024 to date (April 2025);
• I heard from one witness that a ‘good day’ on one side of the wing would just be one incident of self harm, but there would be frequently multiple incidents;
• The number of number of self harm incidents and ACCT documents open appears to have hardened the prison team to expressions of self harm etc. I heard comments throughout the inquest such as “If I opened an ACCT on every woman who said she was suicidal we’d have loads open”, and “2 incidents of self harm in a morning for one prisoner might seem like a lot but it’s not in the context of Styal”. This may lead to key cases being missed;
• The number of ACCTs open within the prison can be high given the mental health need. I have heard evidence from a number of witnesses as to the pressures that the ACCT process places on staff, primarily due to the high number compared to staffing numbers. The severity of this varied in evidence depending seemingly on whether the member of staff was still with the prison service or had left. The clear consensus however was that the carrying out of ACCT checks, meaningful conversations and documentation of this was difficult whilst also trying to manage the day to day regime. It was accepted by the Head of Safer Prisons and Equality at HMP Styal that the officer on duty on the day of Sarah’s death would have been responsible for 48 checks an hour, and that was not unusual. Evidence from one witness, who has since left the prison, was that as a result of the number of checks required, and the limited resource to do them, checks were frequently missed;
• Meaningful conversations, designed to find out how the person is feeling and check in with them, are being carried out by prison officers with very limited mental health training, with very limited time resource to do this. Mental health training is not mandatory for the officers and can be overlooked due to more pressing, mandatory training.
The jury findings record “Understaffing and a high number of ACCT documents at HMP Styal led to inconsistencies with how staff completed each part of the ACCT process”.
In addition to the evidence heard from the witnesses, I am mindful of the report of HM Chief Inspector of Prisons (Time to care: what helps women cope in prison February 2025) which notes that the rate of self harm among women in prison is now 8.5 times higher than in men’s jails, and highlights a number of issues which continue to this, which have been reflected in this inquest.
” 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Insufficient staffing capacity to complete ACCT checks and documentation
Wider context from the report “I am concerned that the ACCT process or system currently in place designed to keep women safe at HMP Styal is not working effectively, and that there is a risk of future deaths if the process is not reconsidered or amended to better suit the needs of this prison. The ACCT process allows for observations of a woman who is at risk of self harm or suicide to keep her safe, but these are not a therapeutic observation and are essentially a check to ensure that the woman is alive and not actively self harming. Mental health input, if a woman is not case loaded to the mental health team, can be minimal, limited to attendance at a case review at best, and this does not allow for an opportunity to improve the woman’s mental health, to reduce the risk of future suicide attempts. Care plans allowing for meaningful activity assist but their effectiveness is limited alongside the prison regime. I acknowledge that prison is not intended to be a therapeutic environment but given the number of women with mental health needs, I am concerned that the current environment or processes will give rise to a risk of future deaths.
My concerns are based on the following points which I heard in evidence:
• HMP Styal is a women’s prison with a high number of self inflicted deaths, compared to the rest of the female estate. I am told by the prison ombudsman that they have the highest number of deaths between January 2022 and January 2025, accounting on my calculation for almost half of the total deaths in the female estate across England. I am aware that there has been one self inflicted death this year to date, and we are only 4 months in;
• I heard evidence from the Head of Safer Prisons and Equality at HMP Styal and the Service Manager for Greater Manchester Mental Health NHS FT, who provide the mental health care in the prison, that the mental health needs of the women detained at Styal are high and can be complex. The latter explained that they receive women from court who have been sent to prison following a criminal act but are essentially awaiting assessment to see whether they should be detained in prison, or in a mental health hospital. The mental health team is then expected to care for the woman for the prolonged period of assessment and awaiting a bed if deemed necessary, something they are not set up to do. It was the view of this witness that Styal was receiving a number of prisoners who are complex and risky and require treatment in a mental health hospital. The process for transfer then takes time and is an additional pressure on the team. The powers of a mental health team in prison are far more restricted, for example, they cannot force medication if needed, and it is reliant on the engagement of prisoners which they frequently do not get. The mental health Trust confirmed that in 2025 to date (29.4.25), 11 prisoners have been referred for a Mental Health Act assessment and of these 11, 8 were accepted for transfer and treatment in a mental health inpatient setting;
• It was the evidence of the Head of Safer Prisons and Equality that they also receive women who are there for a ‘warrant of concern’. A ‘warrant of concern’ is where a woman attends court and is not sentenced at that point but remanded into prison custody due to the Judge having concerns that they are not safe to be released into the community and where it is perceived that they will be safer in custody. This is usually where there are concerns around the woman’s mental health and/or risk to self. This adds pressure on an already stretched resource level in prisons as more resources are generally required to manage such complex individuals; Prison data suggests that HMP Styal have received 7 women on ‘warrants of concern’ since November 2024 to date (April 2025);
• I heard from one witness that a ‘good day’ on one side of the wing would just be one incident of self harm, but there would be frequently multiple incidents;
• The number of number of self harm incidents and ACCT documents open appears to have hardened the prison team to expressions of self harm etc. I heard comments throughout the inquest such as “If I opened an ACCT on every woman who said she was suicidal we’d have loads open”, and “2 incidents of self harm in a morning for one prisoner might seem like a lot but it’s not in the context of Styal”. This may lead to key cases being missed;
• The number of ACCTs open within the prison can be high given the mental health need. I have heard evidence from a number of witnesses as to the pressures that the ACCT process places on staff, primarily due to the high number compared to staffing numbers. The severity of this varied in evidence depending seemingly on whether the member of staff was still with the prison service or had left. The clear consensus however was that the carrying out of ACCT checks, meaningful conversations and documentation of this was difficult whilst also trying to manage the day to day regime . It was accepted by the Head of Safer Prisons and Equality at HMP Styal that the officer on duty on the day of Sarah’s death would have been responsible for 48 checks an hour, and that was not unusual. Evidence from one witness, who has since left the prison, was that as a result of the number of checks required, and the limited resource to do them, checks were frequently missed ;
• Meaningful conversations, designed to find out how the person is feeling and check in with them, are being carried out by prison officers with very limited mental health training, with very limited time resource to do this. Mental health training is not mandatory for the officers and can be overlooked due to more pressing, mandatory training.
The jury findings record “Understaffing and a high number of ACCT documents at HMP Styal led to inconsistencies with how staff completed each part of the ACCT process”.
In addition to the evidence heard from the witnesses, I am mindful of the report of HM Chief Inspector of Prisons (Time to care: what helps women cope in prison February 2025) which notes that the rate of self harm among women in prison is now 8.5 times higher than in men’s jails, and highlights a number of issues which continue to this, which have been reflected in this inquest.
” 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Inconsistent completion of the ACCT process
Wider context from the report “I am concerned that the ACCT process or system currently in place designed to keep women safe at HMP Styal is not working effectively, and that there is a risk of future deaths if the process is not reconsidered or amended to better suit the needs of this prison. The ACCT process allows for observations of a woman who is at risk of self harm or suicide to keep her safe, but these are not a therapeutic observation and are essentially a check to ensure that the woman is alive and not actively self harming. Mental health input, if a woman is not case loaded to the mental health team, can be minimal, limited to attendance at a case review at best, and this does not allow for an opportunity to improve the woman’s mental health, to reduce the risk of future suicide attempts. Care plans allowing for meaningful activity assist but their effectiveness is limited alongside the prison regime. I acknowledge that prison is not intended to be a therapeutic environment but given the number of women with mental health needs, I am concerned that the current environment or processes will give rise to a risk of future deaths.
My concerns are based on the following points which I heard in evidence:
• HMP Styal is a women’s prison with a high number of self inflicted deaths, compared to the rest of the female estate. I am told by the prison ombudsman that they have the highest number of deaths between January 2022 and January 2025, accounting on my calculation for almost half of the total deaths in the female estate across England. I am aware that there has been one self inflicted death this year to date, and we are only 4 months in;
• I heard evidence from the Head of Safer Prisons and Equality at HMP Styal and the Service Manager for Greater Manchester Mental Health NHS FT, who provide the mental health care in the prison, that the mental health needs of the women detained at Styal are high and can be complex. The latter explained that they receive women from court who have been sent to prison following a criminal act but are essentially awaiting assessment to see whether they should be detained in prison, or in a mental health hospital. The mental health team is then expected to care for the woman for the prolonged period of assessment and awaiting a bed if deemed necessary, something they are not set up to do. It was the view of this witness that Styal was receiving a number of prisoners who are complex and risky and require treatment in a mental health hospital. The process for transfer then takes time and is an additional pressure on the team. The powers of a mental health team in prison are far more restricted, for example, they cannot force medication if needed, and it is reliant on the engagement of prisoners which they frequently do not get. The mental health Trust confirmed that in 2025 to date (29.4.25), 11 prisoners have been referred for a Mental Health Act assessment and of these 11, 8 were accepted for transfer and treatment in a mental health inpatient setting;
• It was the evidence of the Head of Safer Prisons and Equality that they also receive women who are there for a ‘warrant of concern’. A ‘warrant of concern’ is where a woman attends court and is not sentenced at that point but remanded into prison custody due to the Judge having concerns that they are not safe to be released into the community and where it is perceived that they will be safer in custody. This is usually where there are concerns around the woman’s mental health and/or risk to self. This adds pressure on an already stretched resource level in prisons as more resources are generally required to manage such complex individuals; Prison data suggests that HMP Styal have received 7 women on ‘warrants of concern’ since November 2024 to date (April 2025);
• I heard from one witness that a ‘good day’ on one side of the wing would just be one incident of self harm, but there would be frequently multiple incidents;
• The number of number of self harm incidents and ACCT documents open appears to have hardened the prison team to expressions of self harm etc. I heard comments throughout the inquest such as “If I opened an ACCT on every woman who said she was suicidal we’d have loads open”, and “2 incidents of self harm in a morning for one prisoner might seem like a lot but it’s not in the context of Styal”. This may lead to key cases being missed;
• The number of ACCTs open within the prison can be high given the mental health need. I have heard evidence from a number of witnesses as to the pressures that the ACCT process places on staff, primarily due to the high number compared to staffing numbers. The severity of this varied in evidence depending seemingly on whether the member of staff was still with the prison service or had left. The clear consensus however was that the carrying out of ACCT checks, meaningful conversations and documentation of this was difficult whilst also trying to manage the day to day regime. It was accepted by the Head of Safer Prisons and Equality at HMP Styal that the officer on duty on the day of Sarah’s death would have been responsible for 48 checks an hour, and that was not unusual. Evidence from one witness, who has since left the prison, was that as a result of the number of checks required, and the limited resource to do them, checks were frequently missed;
• Meaningful conversations, designed to find out how the person is feeling and check in with them, are being carried out by prison officers with very limited mental health training, with very limited time resource to do this. Mental health training is not mandatory for the officers and can be overlooked due to more pressing, mandatory training.
The jury findings record “Understaffing and a high number of ACCT documents at HMP Styal led to inconsistencies with how staff completed each part of the ACCT process ”.
In addition to the evidence heard from the witnesses, I am mindful of the report of HM Chief Inspector of Prisons (Time to care: what helps women cope in prison February 2025) which notes that the rate of self harm among women in prison is now 8.5 times higher than in men’s jails, and highlights a number of issues which continue to this, which have been reflected in this inquest.
” 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Insufficient mental health team capacity for women awaiting assessment or inpatient beds
Wider context from the report “I am concerned that the ACCT process or system currently in place designed to keep women safe at HMP Styal is not working effectively, and that there is a risk of future deaths if the process is not reconsidered or amended to better suit the needs of this prison. The ACCT process allows for observations of a woman who is at risk of self harm or suicide to keep her safe, but these are not a therapeutic observation and are essentially a check to ensure that the woman is alive and not actively self harming. Mental health input, if a woman is not case loaded to the mental health team, can be minimal, limited to attendance at a case review at best, and this does not allow for an opportunity to improve the woman’s mental health, to reduce the risk of future suicide attempts. Care plans allowing for meaningful activity assist but their effectiveness is limited alongside the prison regime. I acknowledge that prison is not intended to be a therapeutic environment but given the number of women with mental health needs, I am concerned that the current environment or processes will give rise to a risk of future deaths.
My concerns are based on the following points which I heard in evidence:
• HMP Styal is a women’s prison with a high number of self inflicted deaths, compared to the rest of the female estate. I am told by the prison ombudsman that they have the highest number of deaths between January 2022 and January 2025, accounting on my calculation for almost half of the total deaths in the female estate across England. I am aware that there has been one self inflicted death this year to date, and we are only 4 months in;
• I heard evidence from the Head of Safer Prisons and Equality at HMP Styal and the Service Manager for Greater Manchester Mental Health NHS FT, who provide the mental health care in the prison, that the mental health needs of the women detained at Styal are high and can be complex. The latter explained that they receive women from court who have been sent to prison following a criminal act but are essentially awaiting assessment to see whether they should be detained in prison, or in a mental health hospital. The mental health team is then expected to care for the woman for the prolonged period of assessment and awaiting a bed if deemed necessary, something they are not set up to do . It was the view of this witness that Styal was receiving a number of prisoners who are complex and risky and require treatment in a mental health hospital. The process for transfer then takes time and is an additional pressure on the team. The powers of a mental health team in prison are far more restricted, for example, they cannot force medication if needed, and it is reliant on the engagement of prisoners which they frequently do not get. The mental health Trust confirmed that in 2025 to date (29.4.25), 11 prisoners have been referred for a Mental Health Act assessment and of these 11, 8 were accepted for transfer and treatment in a mental health inpatient setting;
• It was the evidence of the Head of Safer Prisons and Equality that they also receive women who are there for a ‘warrant of concern’. A ‘warrant of concern’ is where a woman attends court and is not sentenced at that point but remanded into prison custody due to the Judge having concerns that they are not safe to be released into the community and where it is perceived that they will be safer in custody. This is usually where there are concerns around the woman’s mental health and/or risk to self. This adds pressure on an already stretched resource level in prisons as more resources are generally required to manage such complex individuals; Prison data suggests that HMP Styal have received 7 women on ‘warrants of concern’ since November 2024 to date (April 2025);
• I heard from one witness that a ‘good day’ on one side of the wing would just be one incident of self harm, but there would be frequently multiple incidents;
• The number of number of self harm incidents and ACCT documents open appears to have hardened the prison team to expressions of self harm etc. I heard comments throughout the inquest such as “If I opened an ACCT on every woman who said she was suicidal we’d have loads open”, and “2 incidents of self harm in a morning for one prisoner might seem like a lot but it’s not in the context of Styal”. This may lead to key cases being missed;
• The number of ACCTs open within the prison can be high given the mental health need. I have heard evidence from a number of witnesses as to the pressures that the ACCT process places on staff, primarily due to the high number compared to staffing numbers. The severity of this varied in evidence depending seemingly on whether the member of staff was still with the prison service or had left. The clear consensus however was that the carrying out of ACCT checks, meaningful conversations and documentation of this was difficult whilst also trying to manage the day to day regime. It was accepted by the Head of Safer Prisons and Equality at HMP Styal that the officer on duty on the day of Sarah’s death would have been responsible for 48 checks an hour, and that was not unusual. Evidence from one witness, who has since left the prison, was that as a result of the number of checks required, and the limited resource to do them, checks were frequently missed;
• Meaningful conversations, designed to find out how the person is feeling and check in with them, are being carried out by prison officers with very limited mental health training, with very limited time resource to do this. Mental health training is not mandatory for the officers and can be overlooked due to more pressing, mandatory training.
The jury findings record “Understaffing and a high number of ACCT documents at HMP Styal led to inconsistencies with how staff completed each part of the ACCT process”.
In addition to the evidence heard from the witnesses, I am mindful of the report of HM Chief Inspector of Prisons (Time to care: what helps women cope in prison February 2025) which notes that the rate of self harm among women in prison is now 8.5 times higher than in men’s jails, and highlights a number of issues which continue to this, which have been reflected in this inquest.
” 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Insufficient mental health training and time for prison officers conducting meaningful ACCT conversations
Wider context from the report “I am concerned that the ACCT process or system currently in place designed to keep women safe at HMP Styal is not working effectively, and that there is a risk of future deaths if the process is not reconsidered or amended to better suit the needs of this prison. The ACCT process allows for observations of a woman who is at risk of self harm or suicide to keep her safe, but these are not a therapeutic observation and are essentially a check to ensure that the woman is alive and not actively self harming. Mental health input, if a woman is not case loaded to the mental health team, can be minimal, limited to attendance at a case review at best, and this does not allow for an opportunity to improve the woman’s mental health, to reduce the risk of future suicide attempts. Care plans allowing for meaningful activity assist but their effectiveness is limited alongside the prison regime. I acknowledge that prison is not intended to be a therapeutic environment but given the number of women with mental health needs, I am concerned that the current environment or processes will give rise to a risk of future deaths.
My concerns are based on the following points which I heard in evidence:
• HMP Styal is a women’s prison with a high number of self inflicted deaths, compared to the rest of the female estate. I am told by the prison ombudsman that they have the highest number of deaths between January 2022 and January 2025, accounting on my calculation for almost half of the total deaths in the female estate across England. I am aware that there has been one self inflicted death this year to date, and we are only 4 months in;
• I heard evidence from the Head of Safer Prisons and Equality at HMP Styal and the Service Manager for Greater Manchester Mental Health NHS FT, who provide the mental health care in the prison, that the mental health needs of the women detained at Styal are high and can be complex. The latter explained that they receive women from court who have been sent to prison following a criminal act but are essentially awaiting assessment to see whether they should be detained in prison, or in a mental health hospital. The mental health team is then expected to care for the woman for the prolonged period of assessment and awaiting a bed if deemed necessary, something they are not set up to do. It was the view of this witness that Styal was receiving a number of prisoners who are complex and risky and require treatment in a mental health hospital. The process for transfer then takes time and is an additional pressure on the team. The powers of a mental health team in prison are far more restricted, for example, they cannot force medication if needed, and it is reliant on the engagement of prisoners which they frequently do not get. The mental health Trust confirmed that in 2025 to date (29.4.25), 11 prisoners have been referred for a Mental Health Act assessment and of these 11, 8 were accepted for transfer and treatment in a mental health inpatient setting;
• It was the evidence of the Head of Safer Prisons and Equality that they also receive women who are there for a ‘warrant of concern’. A ‘warrant of concern’ is where a woman attends court and is not sentenced at that point but remanded into prison custody due to the Judge having concerns that they are not safe to be released into the community and where it is perceived that they will be safer in custody. This is usually where there are concerns around the woman’s mental health and/or risk to self. This adds pressure on an already stretched resource level in prisons as more resources are generally required to manage such complex individuals; Prison data suggests that HMP Styal have received 7 women on ‘warrants of concern’ since November 2024 to date (April 2025);
• I heard from one witness that a ‘good day’ on one side of the wing would just be one incident of self harm, but there would be frequently multiple incidents;
• The number of number of self harm incidents and ACCT documents open appears to have hardened the prison team to expressions of self harm etc. I heard comments throughout the inquest such as “If I opened an ACCT on every woman who said she was suicidal we’d have loads open”, and “2 incidents of self harm in a morning for one prisoner might seem like a lot but it’s not in the context of Styal”. This may lead to key cases being missed;
• The number of ACCTs open within the prison can be high given the mental health need. I have heard evidence from a number of witnesses as to the pressures that the ACCT process places on staff, primarily due to the high number compared to staffing numbers. The severity of this varied in evidence depending seemingly on whether the member of staff was still with the prison service or had left. The clear consensus however was that the carrying out of ACCT checks, meaningful conversations and documentation of this was difficult whilst also trying to manage the day to day regime. It was accepted by the Head of Safer Prisons and Equality at HMP Styal that the officer on duty on the day of Sarah’s death would have been responsible for 48 checks an hour, and that was not unusual. Evidence from one witness, who has since left the prison, was that as a result of the number of checks required, and the limited resource to do them, checks were frequently missed;
• Meaningful conversations, designed to find out how the person is feeling and check in with them, are being carried out by prison officers with very limited mental health training, with very limited time resource to do this. Mental health training is not mandatory for the officers and can be overlooked due to more pressing, mandatory training.
The jury findings record “Understaffing and a high number of ACCT documents at HMP Styal led to inconsistencies with how staff completed each part of the ACCT process”.
In addition to the evidence heard from the witnesses, I am mindful of the report of HM Chief Inspector of Prisons (Time to care: what helps women cope in prison February 2025) which notes that the rate of self harm among women in prison is now 8.5 times higher than in men’s jails, and highlights a number of issues which continue to this, which have been reflected in this inquest.
” Open source report
11 Mar 2025 Luke Harry Brockwell Barnes · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 3 Insufficient training for frontline probation staff on neurodiverse conditions and their impact on post sentence supervision View source Failure to refer unactioned court sentences back to the court for review View source Failure to ensure probation staff awareness of and access to relevant specialist medical reports View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Luke Harry Brockwell Barnes · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Luke Harry Brockwell Barnes was found dead at his home in Cobham on 9 February 2024 after taking sufficient substance to cause toxicity, and his death was recorded as drug related. The principal concerns included probation staff not having access to relevant specialist reports, whether frontline probation staff had sufficient training about neurodiversity, and a potential loophole where a court-imposed requirement not actioned by probation might not be referred back to the court.
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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Insufficient training for frontline probation staff on neurodiverse conditions and their impact on post sentence supervision
Wider context from the report “b.Whether there is sufficient training for all frontline probation service staff about neurodiverse conditions and their impact on post sentence supervision.
The Court heard from Mr Barnes’ probation practitioner, they had limited awareness of neurodiversity issues as they might affect the supervision of Mr Barnes or probation service policy in this area. Although further evidence from HMPPS confirms that since 2021 all trainee probation officers are required to attend a face-to-face training session on neurodiversity and probation officers and qualified probation officers have training available to them it is not clear if this training is sufficient and for all frontline probation staff .
” 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to refer unactioned court sentences back to the court for review
Wider context from the report “c. That a loophole exists whereby a sentence of the court, not actioned by probation service staff, (in this case a DRR) might not be referred back to the court for 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 HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure probation staff awareness of and access to relevant specialist medical reports
Wider context from the report “a.Probation staff are not always aware of or have access to relevant and/or specialist medical reports prepared for Liaison and Diversion Service and other bodies including mental health providers.
Further evidence obtained from HMPPS indicates that reports prepared for Liaison and Diversion Service or mental health service providers by specialist medical practitioners (including learning disability practitioners) may not always be notified to the probation service and that the sharing of such information relies to an extent on ad hoc arrangements . The coroner has been told that this issue has been identified previously in a Serious Further Offences Review.
” 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 Provide frontline probation staff with training on neurodiversity, including learning disabilities, brain injury, autism and ADHD.
Verbatim wording from the response “All frontline Probation staff have access to training which covers” Source location Response from HMPPS and Probation Service
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 Make the updated Drug Rehabilitation Requirement guidance available to all probation staff through the EQuiP database.
Verbatim wording from the response “The update Guidance documents are available to all Probation staff on a comprehensive computer database known as EQuiP (Excellence & Quality in Process) which provides easy access to operational processes and procedures.” Source location Response from HMPPS and Probation Service
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 Update Drug Rehabilitation Requirement guidance to standardise reviews, clarify roles and responsibilities, and improve the review template.
Verbatim wording from the response “HMPPS has very recently (June 2025) updated its Drug Rehabilitation Requirement (DRR) Guidance (including DRR Reviews Guidance) to help create a standard approach across England and Wales.” Source location Response from HMPPS and Probation Service
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 Keep frontline probation training under review to ensure it remains sufficient, current and relevant to operational demands.
Verbatim wording from the response “This training is a requirement for all those training to become qualified Probation Officers and has been since 2021. HMPPS keeps the training it provides to all Probation frontline staff under review to ensure it is sufficient and current and meets the demands of the work being undertaken. It is part of the professional responsibility of Probation Practitioners to access relevant training to meet the diverse needs of those subject to Probation supervision and ensure that they can comply with the requirements of the Policy Framework for Sentence Management in the Community.” Source location Response from HMPPS and Probation Service
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing training provisions give frontline probation staff access to relevant neurodiversity training and are kept under review.
Verbatim wording from the response “Whether there is sufficient training for all frontline probation service staff about neurodiverse conditions and their impact on post sentence supervision” Source location Response from HMPPS and Probation Service
Open published response
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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 HMCTS is addressing access to Liaison and Diversion reports by removing manual upload requirements from relevant criminal justice systems.
Verbatim wording from the response “Probation staff are not always aware of or have access to relevant and/or specialist medical reports prepared for Liaison and Diversion Service and other bodies including mental health providers.” Source location Response from HMPPS and Probation Service
Open published response
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations