Concerns raised 5 Failure of some mental healthcare trusts to accept referrals for homeless prisoners on release View source Unavailability of National Record Locator access for South West ambulance care in Dorset View source Lack of guidance and tools for assessing violence risk in MOSOVO-managed offenders View source Lack of a process for sharing remanded prisoners’ risk information with sentencing courts View source Lack of practical national guidance for continuity of prisoners’ healthcare on release View source See 2 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
Marta Elena Vento · 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
Marta Elena Vento was working alone as a hotel receptionist in Bournemouth when she was fatally beaten in an unprovoked attack on 9 December 2020. The report raises concerns about the sharing of remand prisoners’ risk information with sentencing courts, continuity of mental healthcare after release from prison, risk assessment of violent offenders managed by MOSOVO units, and access to patient information through the National Record Locator.
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 some mental healthcare trusts to accept referrals for homeless prisoners on release
Wider context from the report “Evidence was given that this is not the process nationally in that some mental healthcare trusts will not accept a referral if a person is homeless . There is no national guidance about the continuity of care for prisoners upon release from prison when homeless .
I am concerned that this lack of continuity of care 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 National Record Locator access for South West ambulance care in Dorset
Wider context from the report “Evidence was given by the Head of Clinical Development and Organisational Development at South West Ambulance Service NHS Foundation Trust (SWAST) that in the South West region all Integrated Care Boards (ICBs), apart from the ICB in Dorset, NHS Dorset, are at some stage of implementing the use of NRL so that SWAST can access this information to assist in the provision of care to those they treat.
Evidence was given that as this would limit the information SWAST had access to about a patient in Dorset , this would impact upon the care provided to those in Dorset by SWAST which could lead to a future 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 Lack of guidance and tools for assessing violence risk in MOSOVO-managed offenders
Wider context from the report “The risk assessments detailed in the guidance are aimed at the assessment of the sexual risk of offenders and evidence was given that there is no bespoke risk assessment tool or guidance to assess the violence of such offenders to assist staff within MOSOVO units to undertake their role . There is, therefore, a lack of guidance on how to risk assess and manage offenders who are managed under MOSOVO when they present with the risk of violence, or an escalating risk of violence .
I am concerned that this will result in a failure to identify the risk of violence, or the increasing risk of violence, in those being managed by MOSOVO which may lead to a further 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 Lack of a process for sharing remanded prisoners’ risk information with sentencing courts
Wider context from the report “Evidence was given by the Head of the Offender Management Unit (OMU) at HMP Winchester, a Senior Probation Officer, that there is currently no formal process or guidance in place for the sharing of information by a prison with the Criminal Courts to provide an update of the person's behaviour in prison which may increase their risk of harm or risk offending .
It was explained that the person who could enquire about this at Court, if asked, would be the duty Probation Officer, and that this is especially more challenging to complete when a fast delivery report is requested.
There is currently no process from a prison perspective to share information to the sentencing Court other than that contained within the Prison Escort Record (PER), which is not provided to the sentencing Judge, the lawyers at Court or Probation staff .
I am concerned that the full extent of a remanded prisoner’s risk of harm to the public may not be appreciated by the sentencing Judge, which could impact upon the sentence imposed upon a prisoner and I am concerned that this lack of sharing of information 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 practical national guidance for continuity of prisoners’ healthcare on release
Wider context from the report “There is a lack of national guidance to assist all healthcare providers to ensure continuity of care for a prisoner with health care needs, whether physical or mental health needs, upon release from prison . There are national standards of care and NICE guidelines in place, however none of these provide practical guidance around the delivery of care to ensure continuity of care .
” 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 Ask the HMPPS Safety Group to consider court risk-information sharing during its forthcoming Prison Safety Policy Framework review.
Verbatim wording from the response “of sharing with courts information about behaviour in custody that may impact on risk of harm or offending. In response to the concerns that you have raised, I have asked the Safety Group in HMPPS to give further consideration to this specific area when they undertake a review of this policy framework later in the 2026-26 business year. This will be informed by the results of the pathfinder projects described above.” 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 Operate immediate-release pathfinders in three prisons to develop multi-agency identification, support, management and information-exchange approaches.
Verbatim wording from the response “The National Immediate Release Task and Finish Group has established immediate release pathfinders in three prisons, with a focus on developing multi-agency approaches to identify in advance those people who may be immediately released from court and to take steps to ensure that they are supported and managed effectively. This includes exploring methods of information exchange for those on remand who have an upcoming court case which may result in immediate release.” Source location Response from HM Prison & Probation Service
Open published response
7 Feb 2025 Anthony Binfield and 2 others · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 14 Inadequate basic training, supervision and mentoring of prison staff View source Inadequate prison and healthcare staffing levels View source Failure to act with candour in post-death investigations View source Use of inaccessible email channels for risk pertinent information View source Failure to identify and share risk pertinent information between prison and healthcare staff View source Insufficient safety scrutiny during prison contract transfer View source Failure to reduce isolation of foreign national prisoners View source Failure to embed learning from deaths and monitor safety culture View source Failure to provide a nurse during night state View source Unreliable and delayed access to interpretation services for foreign national prisoners View source Lack of an effective system for gathering, retaining, reviewing and disclosing investigation material View source Failure to retain sufficient experienced prison and healthcare staff View source Lack of effective NPS-specific drug policy View source Lack of a formal prison-to-prison transfer management system View source See 11 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 16
Action
Operate local drug-strategy governance, staffing, supply-restriction, harm-reduction and recovery measures at Lowdham Grange.
Stated completedThe respondent said that this action was complete when they made their response on 13 February 2025. View source
Action
Work with NHS England to devise revised guidance on information-sharing in prison reception areas, including healthcare access to digital Person Escort Records.
Stated in progressThe respondent said that this action was in progress when they made their response on 13 February 2025. View source
Action
Conduct pre-expiry safety audits at private prisons and share reports and recommendations with responsible HMPPS teams.
Stated plannedThe respondent said that this action was planned when they made their response on 13 February 2025. View source
Action
Introduce risk-sharing measures, including a triggers database and improved shift handovers, first-night processes and induction.
Stated in progressThe respondent said that this action was in progress when they made their response on 13 February 2025. View source
Action
Improve mobilisation planning through revised document timelines, a staff communications toolkit and updated phase guidance.
Stated completedThe respondent said that this action was complete when they made their response on 13 February 2025. View source
Action
Amend future prison competitions to require culture plans and strengthen safety evaluation and safety-risk responses.
Stated completedThe respondent said that this action was complete when they made their response on 13 February 2025. View source
Action
Conduct safety-focused visits to expiring private prisons during mobilisation and transition, and share findings with sites.
Stated plannedThe respondent said that this action was planned when they made their response on 13 February 2025. View source
Action
Refresh the Safety Intervention Meeting to improve multidisciplinary information-sharing and strategic support for prisoners at risk.
Stated in progressThe respondent said that this action was in progress when they made their response on 13 February 2025. View source
Action
Use Reports to Prevent Future Deaths to identify safety themes and disseminate learning through guidance, bulletins and group safety-lead meetings.
Stated completedThe respondent said that this action was complete when they made their response on 13 February 2025. View source
Action
Develop collaborative information-sharing arrangements between the prison and healthcare provider and reinforce use of designated information systems.
Stated in progressThe respondent said that this action was in progress when they made their response on 13 February 2025. View source
Action
Recruit an FNO manager to support foreign national prisoners and develop assurance of Big Word use.
Stated in progressThe respondent said that this action was in progress when they made their response on 13 February 2025. View source
Action
Provide mentors, induction guidance, buddy support and line-manager packages for new and less experienced prison staff.
Stated completedThe respondent said that this action was complete when they made their response on 13 February 2025. View source
Action
Provide recruitment, retention and staffing support to improve workforce levels at Lowdham Grange.
Stated in progressThe respondent said that this action was in progress when they made their response on 13 February 2025. View source
Action
Provide consolidated prison information and improved operating-procedure processes for bidders and incoming operators.
Stated completedThe respondent said that this action was complete when they made their response on 13 February 2025. View source
Action
Provide synthetic-cannabinoid risk training through an eLearning package for prison staff.
Stated completedThe respondent said that this action was complete when they made their response on 13 February 2025. View source
Action
Establish a meeting focused on addressing issues raised in Reports to Prevent Future Deaths.
Stated completedThe respondent said that this action was complete when they made their response on 13 February 2025. View source See 13 more actions
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AI-generated summary
Anthony Binfield and 2 others · 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
Anthony Binfield, David William Richards and Rolandas Karbauskas died at HMP Lowdham Grange in March 2023 after using ligatures; Anthony’s and Rolandas’s deaths were suicides, while David’s death was accidental. The report identified missed opportunities to recognise and share risk information, shortcomings in prison and healthcare staffing, training and systems, and concerns about prisoner transfers, isolation, the prison contract transfer, and learning from previous 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 Inadequate basic training, supervision and mentoring of prison staff
Wider context from the report “All of the prison staff had completed the ITC programme, and yet there was widespread evidence of failures to do the basics . Staff failed to ensure the welfare of prisoners at roll count, failed to challenge flagrant breaches of Prison rules such as passing items under cell doors, and did not know how to properly deal with obscured cell observation hatches.
This calls into question the adequacy of their basic training, and the system for supervision and mentoring during the early years of practice.
” 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 prison and healthcare staffing levels
Wider context from the report “The inadequate prison and healthcare staffing levels led to a restricted regime and healthcare provision. The prison was unable to offer keywork to all men, and the mental health team could no longer offer a named nurse service. Both of these aspects of care are fundamental to supporting the most 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 act with candour in post-death investigations
Wider context from the report “The Healthcare Trust are subject to a statutory duty of candour. HMPPS, Serco and Sodexo failed to embrace the same ethos during these investigations.
” 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 Use of inaccessible email channels for risk pertinent information
Wider context from the report “I am also concerned by the use of email to convey risk pertinent information . In this case, prison staff communicated their concerns about Anthony’s mental health to individual nursing Sodexo email inboxes, which the nurses were not expected to regularly access . The use of email means that such concerns are not accessible to other members of staff as they would be if they were recorded in PNOMIS or Systemone.
” 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 identify and share risk pertinent information between prison and healthcare staff
Wider context from the report “There was a complete breakdown in the system of risk identification and information sharing . Prison and healthcare staff did not routinely consider information captured within the electronic systems , nor did they update the systems with risk pertinent information gathered during interactions with the 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 Insufficient safety scrutiny during prison contract transfer
Wider context from the report “Safety was not front and centre of the Mobilisation and Transfer project.
” 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 reduce isolation of foreign national prisoners
Wider context from the report “I heard evidence that the Big Word translation service did not work on multiple occasions across multiple sites within the prison. Staff gave evidence that even when the system did connect, they could be waiting in a queue for up to an hour to access an appropriate interpreter.
There was no plan to seek to reduce Rolandas’ obvious isolation , and seemingly no provision for expediting his induction so that he could be housed with fellow Lithuanian speakers .
” 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 embed learning from deaths and monitor safety culture
Wider context from the report “I heard evidence that many of the contributory factors leading to the deaths of Anthony, David and Rolandas, had been raised as issues in the investigations following previous deaths in custody at HMP Lowdham Grange.
While Serco no longer manage HMP Lowdham Grange, they continue to manage prisons, and there is a risk of future deaths if the organisation is unable to create a robust culture of seeking to identify issues early, adopt learning, and continually monitor culture to ensure any action taken is embedded to reduce the 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 a nurse during night state
Wider context from the report “For months prior to the deaths, the Trust failed to fulfil its commissioned obligations to provide a nurse during night state . Prison staff have only basic first aid training and lacked the expertise of a medical professional when attempting to provide CPR to Anthony.
” 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 Unreliable and delayed access to interpretation services for foreign national prisoners
Wider context from the report “I heard evidence that the Big Word translation service did not work on multiple occasions across multiple sites within the prison . Staff gave evidence that even when the system did connect, they could be waiting in a queue for up to an hour to access an appropriate interpreter .
There was no plan to seek to reduce Rolandas’ obvious isolation, and seemingly no provision for expediting his induction so that he could be housed with fellow Lithuanian speakers.
” 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 an effective system for gathering, retaining, reviewing and disclosing investigation material
Wider context from the report “HMPPS have no effective system for gathering, retaining, reviewing and disclosing potentially relevant material so that the issues relevant to death can be identified and learning put in place.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to retain sufficient experienced prison and healthcare staff
Wider context from the report “I am concerned by the failure to retain experienced prison officers and healthcare staff . The private prison operator and the Authority were focused on the number of staff, rather than the skill sets or experience of the staffing body as a whole .
” 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 effective NPS-specific drug policy
Wider context from the report “There is no requirement for prisons to have an NPS specific drug policy and I am concerned that generic drug reduction strategies are ineffective against this particular threat .
NPS is highly dangerous and carries a risk of death. I am concerned that more young men will die in custody as a result of NPS use.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Lack of a formal prison-to-prison transfer management system
Wider context from the report “I heard evidence that there is no formal policy framework or system for managing the progress of prison-to-prison transfers , including a lack of expected response times or formal escalation plan if a prison fails to provide any 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 Operate local drug-strategy governance, staffing, supply-restriction, harm-reduction and recovery measures at Lowdham Grange.
Verbatim wording from the response “At Lowdham Grange the drug strategy is overseen at a monthly meeting attended by senior leaders and operational managers, and there are two dedicated drug strategy officers in place. Supply restriction measures include work to prevent drone drops, body scans for prisoners, and a network of security liaison officers are on each houseblock to ensure that information on those organising and using illicit items is passed on. Future plans include the installation of windows that will prevent the entry of parcels and a publicity programme to raise awareness in the community of the drone problem and to encourage the reporting of suspicious behaviour. The local drug strategy also includes various measures to reduce demand, enable recovery and reduce harm. These include a video on the dangers of synthetic opioids that was created” 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 Work with NHS England to devise revised guidance on information-sharing in prison reception areas, including healthcare access to digital Person Escort Records.
Verbatim wording from the response “We know that achieving full compliance with these policies can be challenging and we continue to work with healthcare partners and others to support Governors in implementing them, including through the HMPPS/NHSE Information Sharing Advisory Group which meets regularly to tackle issues in this area. For example, we are currently working with NHSE to devise revised guidance on information sharing in prison reception areas, focused particularly on healthcare staff access to the digital Person Escort Records (dPER).” 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 Conduct pre-expiry safety audits at private prisons and share reports and recommendations with responsible HMPPS teams.
Verbatim wording from the response “We have also agreed with the Performance, Assurance, Risk (PAR) Group to conduct Safety Audits at these sites, closer to the mobilisation period. The Safety Audits are usually unannounced, however, given the challenging nature of transferring a site from one Operator to another, we have agreed that these safety audits are carried out 6 – 9 months prior to expiry for these sites (the incumbent operator still won’t be notified prior to them going in). Final” 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 Introduce risk-sharing measures, including a triggers database and improved shift handovers, first-night processes and induction.
Verbatim wording from the response “The identification and management of risk is a vital element of core prison officer duties. A range of measures are being introduced by the SMT at Lowdham Grange to ensure risks are” 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 Improve mobilisation planning through revised document timelines, a staff communications toolkit and updated phase guidance.
Verbatim wording from the response “Improvements have also been made to the mobilisation process as a result of the findings of this inquest. Timelines for submission of key mobilisation documents such as local operating procedures have been revised to enable a new operator to stagger activity and keep focused on operations and critical systems in the lead up to handover and a staff communications toolkit has been developed to ensure alignment of messaging between all parties.” 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 Amend future prison competitions to require culture plans and strengthen safety evaluation and safety-risk responses.
Verbatim wording from the response “As stated at the inquest, we are committed to learning from the experience of the transfer of Lowdham Grange from one provider to another to inform subsequent competitions for contracts and their mobilisation, and a number of changes have already been made in response.” 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 safety-focused visits to expiring private prisons during mobilisation and transition, and share findings with sites.
Verbatim wording from the response “Visits to expiring private prisons have been agreed with the HMPPS National Safety Group during the mobilisation stage, focusing on the early days processes including reception, first night and induction, with a follow up visit during the transition period. The Safety Group share their findings via a report to the site to ensure all parties are aware of what areas need focus.” 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 Refresh the Safety Intervention Meeting to improve multidisciplinary information-sharing and strategic support for prisoners at risk.
Verbatim wording from the response “The Safety Intervention Meeting (SIM) is being refreshed so that it provides a more effective mechanism for all those involved in the care of prisoners and to discuss those at risk, share information and ensure a strategic overview that pulls in all relevant information and agencies to ensure support is tailored to the individual. The Governor is committed to learning from deaths that have occurred and has introduced a meeting to focus on work to address issues raised in Reports to Prevent Future Deaths.” 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 Use Reports to Prevent Future Deaths to identify safety themes and disseminate learning through guidance, bulletins and group safety-lead meetings.
Verbatim wording from the response “More generally HMPPS is committed to learning from all deaths and to taking action to address any issues that are identified as a result. The Follow-up to Deaths in Custody policy framework describes the early learning review process for all apparently non-natural deaths, through 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. It also explains our commitment to supporting the various independent investigations processes that follow a death and particularly to meeting our duty of candour, including by disclosing all relevant documents.” 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 Develop collaborative information-sharing arrangements between the prison and healthcare provider and reinforce use of designated information systems.
Verbatim wording from the response “Work is also ongoing to create a positive and collaborative relationship between the prison and the healthcare provider, to build better working relationships and ensure all are aware of their responsibilities in sharing information with colleagues. It will be reinforced to staff in all areas that information should be shared using the relevant systems, such as NOMIS, SystmOne, and observation books, rather than through emails.” 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 Recruit an FNO manager to support foreign national prisoners and develop assurance of Big Word use.
Verbatim wording from the response “Locally, Lowdham Grange is recruiting for an FNO manager who will ensure FNOs are effectively managed and supported, as well as developing an assurance process to determine the use of Big Word.” 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 mentors, induction guidance, buddy support and line-manager packages for new and less experienced prison staff.
Verbatim wording from the response “Following the introduction of New Colleague Mentors, made up of experienced staff to support newly arrived prison officers, an ‘Induction Passport’ has been created. This document provides comprehensive information and guidance on the key duties of staff, as well as detail on how to seek support. Alongside the Induction Passport a ‘buddy’ system is in place, providing new recruits with a link to a more experienced member of staff to provide support and guidance. Packages have also been delivered to line managers to help them steer new and less experienced staff confidently and effectively.” 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 recruitment, retention and staffing support to improve workforce levels at Lowdham Grange.
Verbatim wording from the response “Since taking over the management of Lowdham Grange HMPPS has taken a number of steps to improve recruitment and retention, including the provision of additional support to the prison to undertake recruitment activity.” 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 consolidated prison information and improved operating-procedure processes for bidders and incoming operators.
Verbatim wording from the response “To assist bidders with a better understanding of the prison at the point of competition, the project now provides a Current Regime and Services document as part of the Prison Specific Competition Data Room. This amalgamates previous disparate pieces of information and provides more detailed data, so bidders have a clear overview of all aspects of the prison. The project has also introduced an improved process for operating procedures from HMP Altcourse mobilisation onwards, which assists incoming Operators in identifying current processes in place and provides them with clear templates and guidance to streamline the process.” 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 synthetic-cannabinoid risk training through an eLearning package for prison staff.
Verbatim wording from the response “However, to ensure staff understand the risks specific to PS use, an eLearning package is available for all staff to access. This course has been designed to increase awareness of the types of synthetic cannabinoids; understanding their effects, how to deal with them and where to signpost for support to assist staff in reducing the demand for these substances, managing the associated risks and promoting recovery from dependency.” 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 Establish a meeting focused on addressing issues raised in Reports to Prevent Future Deaths.
Verbatim wording from the response “The Safety Intervention Meeting (SIM) is being refreshed so that it provides a more effective mechanism for all those involved in the care of prisoners and to discuss those at risk, share information and ensure a strategic overview that pulls in all relevant information and agencies to ensure support is tailored to the individual. The Governor is committed to learning from deaths that have occurred and has introduced a meeting to focus on work to address issues raised in Reports to Prevent Future Deaths.” 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 Existing document-retention guidance is considered sufficient to meet coroners’ needs in the vast majority of cases.
Verbatim wording from the response “I am sorry that there were delays in the disclosure of material during these inquests. We have reviewed the handling of the inquests with Government Legal Department (GLD) and we believe that this was the result of the unusual circumstances of this case, which had a broad scope that reached into areas not commonly subject to such investigation. The Follow-up to Deaths in Custody policy framework sets out very clearly the requirement to retain documents relevant to the death and specifically notes that there may be a considerable delay between the death and the inquest, and that the coroner may ask for documentation not requested by either the police or the PPO, pointing out that it is therefore crucial that prisons retain all documentation available. In the vast majority of cases prisons are complying with this guidance and it is proving sufficient to meet the needs of coroners.” 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 The existing approach of allowing juries to determine findings, without routine formal admissions, is considered to meet the duty of candour.
Verbatim wording from the response “To date we have considered this approach to meet our duty of candour and have not routinely sought to make formal admissions in the way that you have advocated. Rather it has seemed appropriate to us to allow the jury to make their findings based on the evidence, as elicited by the Coroner and the representatives of the interested parties. Not making formal admissions in the context of the inquest does not imply any reluctance on our part to acknowledge failures or any lack of will to learn from them.” 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 Supplier data shows no current evidence of telephone interpretation waiting times exceeding one hour at Lowdham Grange.
Verbatim wording from the response “During the inquest you heard evidence concerning access to The Big Word translation service. The Ministry of Justice is committed to ensuring that the justice system is supported by high-quality language services that meet the needs of all users. In 2016, Thebigword Group Ltd was appointed as the supplier of language services, specifically spoken face-to-face, telephone, and video interpretation services, as well as foreign language-related translation and transcription services. The department’s contracts provide a robust governance structure and performance regime, including the monitoring of telephone interpretation usage compliance with the contracted standards. Thebigword has confirmed that their data shows no evidence presently of waiting times over an hour to service any calls at Lowdham Grange.” Source location Response from HMPPS
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 Healthcare staffing is the responsibility of the healthcare provider, which has responded separately.
Verbatim wording from the response “As heard at the inquest, the transition detailed above significantly impacted on a challenging recruitment picture and the low staffing levels along with a reduction in staff with a significant length of service and experience. As you are aware, healthcare staffing is a matter for the healthcare provider, who have responded separately.” Source location Response from HMPPS
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 Each prison is responsible for understanding local psychoactive-substance risks and developing local strategies to manage them.
Verbatim wording from the response “HMPPS has a prison drug strategy that adopts a whole system approach to restricting supply and reducing the demand for drugs and to building recovery. PS is often used in conjunction with other drugs, and as a result our strategy sets out a set of principles and actions that are sufficiently flexible to apply across the estate, rather than a drug-specific approach. As the risk and impact of drug and alcohol use is variable between prisons it is the responsibility of each prison to understand local risk and develop local strategies to ensure the risks are identified, understood, and effectively managed.” Source location Response from HMPPS
Open published response
27 Jan 2025 WILLIAM CAMPBELL BISSETT · Prevention of Future Deaths report Liverpool and the Wirral
View report summary
Concerns raised 5 Failure to engage prisoners about accommodation when they cannot find housing View source Failure to commence accommodation planning with the relevant local authority View source Failure to inform local authorities of impending prisoner homelessness before release View source Failure to arrange an early pre-release meeting with prisoners View source Failure to provide support to prisoners facing permanent separation from their spouses View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
WILLIAM CAMPBELL BISSETT · 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
William Campbell Bissett, aged 88, died by suicide by hanging in his cell at HMP Wymott on 13 October 2023, shortly before his planned release on licence. The report raised concerns about inadequate advance planning for his accommodation, insufficient engagement by prison offender management and probation services, and the failure to notify local authorities that he would be homeless on release.
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 engage prisoners about accommodation when they cannot find housing
Wider context from the report “(2) On 23rd June 2023 Mr Bissett was informed of the terms of his licence upon release. He was informed that he would not be allowed to return home. No sufficient attempt was made to engage with Mr Bissett to discuss accommodation in the event that he was unable to find a place to live himself.
” 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 commence accommodation planning with the relevant local authority
Wider context from the report “(3) 56 days before release, it being clear that Mr Bissett had nowhere to go, planning for accommodation should have been commenced with Fylde Borough Council who would have the duty to provide temporary housing and who would have engaged with Mr Bissett to discuss his requirements.
” 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 inform local authorities of impending prisoner homelessness before release
Wider context from the report “(4) 56 days before release HMP Wymott should have informed the Fylde Coast Local Authorities that Mr Bissett would be homeless upon release so that his name appeared on the agenda for the monthly Prison Release Meeting. This was not done.
” 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 arrange an early pre-release meeting with prisoners
Wider context from the report “(1) Evidence was heard to the effect that in the 8-month period before a prisoner is released arrangements for release are the responsibility of the Community Offender Manager with the Prison Offender Manager acting as a conduit of information. Further it was said that the Community Offender Manager should arrange an early meeting with the prisoner. Mr Bissett a man aged 88 in failing health only saw his Community Offender Manager on 5th October 2023, 8 days before his release .
” 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 support to prisoners facing permanent separation from their spouses
Wider context from the report “(5) Lack of planning for release and lack of engagement left Mr Bissett only with the knowledge that he would probably have to live the rest of his life separated from his wife. No attempt was made to help him come to terms with this reality.
” Open source report
20 Dec 2024 Haydar Jefferies · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 11 Unavailability of medication for acute mental health symptoms overnight View source Unavailability of clinical mental health provision outside weekday office hours View source Failure to record prisoner welfare information provided in telephone calls View source Lack of a composite 24-hour information document for clinicians reviewing CSU prisoners View source Lack of custody staff training to recognise red flags of declining mental health View source Failure to verify completion of requested mental health referrals View source Failure to consolidate and disseminate prisoner concerns in daily briefing sheets View source Insufficient overnight staffing to take prisoners in mental health crisis to hospital View source Failure to provide necessary clinical knowledge for overnight mental health risk assessment View source Failure of the ACCT process to protect non-suicidal prisoners in acute mental health crisis View source Lack of a process to expedite face-to-face parole hearings for eligible IPP prisoners View source See 8 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
Haydar Jefferies · 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
Haydar Jefferies was detained at HMP Coldingley and developed severe depression and psychosis before self-ligaturing in his cell on 1 March 2023; he was resuscitated but died at hospital on 5 March 2023 from hypoxic brain injury and pneumonia. The principal concerns included failures to record and share risk-relevant information, refer him promptly to mental health services, provide an adequate mental health assessment and obtain appropriate clinical care and supervision during his acute deterioration.
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 medication for acute mental health symptoms overnight
Wider context from the report “6. Outside of weekday office hours there is no clinical mental health provision. Overnight staffing levels are such that it is difficult for prisoners in mental health crisis to be taken to hospital. As a result:
a.) custodial staff take decisions about how to keep prisoners safe overnight without the necessary clinical knowledge to assess the risks presented by their mental health conditions.
b.) it is not possible for medication to be obtained to alleviate any acute mental health symptoms between 6.30 pm and 7am the following morning .
” 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 clinical mental health provision outside weekday office hours
Wider context from the report “6. Outside of weekday office hours there is no clinical mental health provision . Overnight staffing levels are such that it is difficult for prisoners in mental health crisis to be taken to hospital. As a result:
a.) custodial staff take decisions about how to keep prisoners safe overnight without the necessary clinical knowledge to assess the risks presented by their mental health conditions.
b.) it is not possible for medication to be obtained to alleviate any acute mental health symptoms between 6.30 pm and 7am the following morning.
” 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 prisoner welfare information provided in telephone calls
Wider context from the report “1. There is no system in place to ensure that information provided in telephone calls in relation to a prisoner’s welfare is recorded .
” 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 composite 24-hour information document for clinicians reviewing CSU prisoners
Wider context from the report “3. There is no composite document for clinicians to review to see all relevant information recorded by custodial staff about a CSU prisoner for the proceeding 24 hour period .
” 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 custody staff training to recognise red flags of declining mental health
Wider context from the report “5. Custody staff are not trained in mental health presentations and are unable to recognise red flag indicators of declining mental health .
” 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 verify completion of requested mental health referrals
Wider context from the report “4. There is no system in place to check that referrals to the mental health teams requested by senior members of the prison staff have in fact been made .
” 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 consolidate and disseminate prisoner concerns in daily briefing sheets
Wider context from the report “2. Matters of concern in relation to prisoners are recorded across a number of different records and there is a risk that the information is missed and not disseminated in daily briefing sheets .
” 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 overnight staffing to take prisoners in mental health crisis to hospital
Wider context from the report “6. Outside of weekday office hours there is no clinical mental health provision. Overnight staffing levels are such that it is difficult for prisoners in mental health crisis to be taken to hospital . As a result:
a.) custodial staff take decisions about how to keep prisoners safe overnight without the necessary clinical knowledge to assess the risks presented by their mental health conditions.
b.) it is not possible for medication to be obtained to alleviate any acute mental health symptoms between 6.30 pm and 7am the following morning.
” 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 necessary clinical knowledge for overnight mental health risk assessment
Wider context from the report “6. Outside of weekday office hours there is no clinical mental health provision. Overnight staffing levels are such that it is difficult for prisoners in mental health crisis to be taken to hospital. As a result:
a.) custodial staff take decisions about how to keep prisoners safe overnight without the necessary clinical knowledge to assess the risks presented by their mental health conditions .
b.) it is not possible for medication to be obtained to alleviate any acute mental health symptoms between 6.30 pm and 7am the following morning.
” 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 the ACCT process to protect non-suicidal prisoners in acute mental health crisis
Wider context from the report “7. The ACCT process is not designed nor effective to protect prisoners in acute mental health crisis who do not appear to be suicidal .
” 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 process to expedite face-to-face parole hearings for eligible IPP prisoners
Wider context from the report “8. Imprisonment under an IPP is a recognised suicide risk. The delay in dealing with the IPP parole hearing exacerbated the risk. There is currently no process in place to expedite face to face parole hearings for IPP prisoners when allegations leading to their recall have been withdrawn and no criminal action is being considered .
” 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 Introduction to Mental Health Awareness training to all new prison officers through initial prison officer training.
Verbatim wording from the response “In addition to the action taken locally at HMP Coldingley, I can confirm that all new prison officers complete a training module called ‘Introduction to Mental Health Awareness’ as part of their initial prison officer training.” 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 Redesign and digitise the mental health referral process, requiring documentation of senior referral requests and assigned completion responsibility.
Verbatim wording from the response “Your final concerns relate to prison staff’s awareness of mental health, including making referrals to the mental health team and recognising when a prisoner’s mental health is declining. Following Mr Jefferies’ death, the mental health referral process was reviewed and the referral form was redesigned to simplify the process. The form is now available electronically so that staff can easily access it when needed, and when a referral has been requested by a senior member of staff they must document that this request has been made and record the name of the staff member tasked with completing the referral. Through improved multi-disciplinary working, there are more opportunities to check that referrals to the mental health team have been completed and received by the mental health team.” 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 Pilot mandatory online Introduction to Mental Health training for Care and Separation Unit staff, including all new staff applying to work there.
Verbatim wording from the response “The prison is piloting an online e-learning course called ‘Introduction to Mental Health’ for all staff working in the CSU to support staff in identifying indicators of declining mental health and to upskill staff to complete the mental health referral forms with relevant risk information. All new staff applying to work in the CSU must complete this course.” 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 Hold morning multidisciplinary briefings for Care and Separation Unit staff, healthcare and mental health colleagues to share documented concerns before healthcare rounds.
Verbatim wording from the response “You have raised a concern that there is no composite document for clinicians to review which contains relevant information recorded by prison staff about prisoners in the Care and Separation Unit (CSU). There is now a morning briefing for CSU staff, attended by healthcare and the mental health team which takes place prior to healthcare’s rounds, when all CSU prisoners are reviewed. Documented concerns are shared each morning at the briefing. Collaborative working and communication between prison staff, healthcare and mental health colleagues has improved through multi-disciplinary meetings which support the sharing of relevant risk information and actions to help prisoners identified as at risk of suicide and self-harm.” 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 Record and share prisoner welfare concerns through P-NOMIS, Safety team notification, daily briefings and Safety Intervention Meetings.
Verbatim wording from the response “You have raised concerns that there is no system in place to record welfare concerns about prisoners when they are reported into the prison, and that when matters of concern are recorded this is not always documented in the same place. I have received assurance from the Governing Governor of HMP Coldingley that the prison has developed and embedded a new process to ensure that important information relating to the welfare of prisoners is recorded and shared appropriately. Any contact from a concerned relative or friend of a prisoner must be logged as a case note on P-NOMIS, the National Offender Management Information System used by the prison service, and the Safety team must be informed. That information is then added to the daily briefing sheet and discussed at the next Safety Intervention Meeting (SIM), a weekly multi-disciplinary meeting where the most at risk” 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 Require relevant managers to consider out-of-hours mental-health support options, including NHS 111, when concerns are raised.
Verbatim wording from the response “The prison’s Safety Strategy also sets out that all managers, particularly night Orderly Officers and those in charge of the prison when healthcare colleagues are not available, must consider using out of hours options when concerns for a prisoner’s mental health have been raised. This includes phoning 111 – the NHS emergency non-life threatening phone number which now offers mental health crisis support.” Source location Response from HMPPS
Open published response
25 Nov 2024 Jonathon Paul LAWLOR · Prevention of Future Deaths report Mid Kent and Medway
View report summary
Concerns raised 1 Failure to provide sufficient key-working sessions for prisoners View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jonathon Paul LAWLOR · 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
Jonathon Paul LAWLOR was held on remand at HMP Elmley and was found unresponsive in his cell on 19 October 2023. CPR and emergency treatment were provided, but he was declared dead at 11:47 hours; the post-mortem identified cocaine toxicity, and the inquest concluded that he died as a result of an accident. The principal concern was that he had received only two keywork sessions during four months on remand, reportedly because of staff shortages, raising broader concerns about the availability and suitability of keyworking for 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 Failure to provide sufficient key-working sessions for prisoners
Wider context from the report “(1) Mr. Lawlor only had two keywork sessions during the 4 months he was on remand at HMP Elmley. The reasons given were that staff shortages meant that key working sessions were not able to be offered . Offender Management in Custody(OMiC) guidance suggests that good practice entails an officer having a caseload of five or six prisoners who they will meet once a week for a key working meeting. The Prison and Probation Ombudsman who also investigated the death were aware that due to staff shortages the priority at the time of Mr. Lawlor's death were to have monthly sessions and that the prison was to increase provision as their staffing picture improved. On that basis they made no recommendations.
Whilst the number of keywork sessions Mr. Lawlor had did not play a part in his death it may be the case that key-working sessions for prisoners can assist with reducing risks for others in custody. Evidence heard at the inquest revealed that the target had been unachievable due to staffing pressures and as a large number of prisoners (approximately 70%) are on remand and stay between zero and six months the turnover is high and the prison is busy. There was also some scepticism as to whether it was the right model.
” 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 Implement the new regime and business planning process to support increased quantity and quality of key work.
Verbatim wording from the response “In January 2024 I wrote to all Area Executive Directors, Prison Group Directors and Governors setting out the HMPPS operational priorities for 2024/5 and the related core expectations. One of these priorities was to increase the quantity and quality of regimes, including key work, and to support this a new regime and business planning process has been introduced.” 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 Add key-work delivery elements to the Regime Planning Template for establishments to use in regime planning.
Verbatim wording from the response “Key work is one of the core priorities for HMPPS in 2025/26. The expectation will be that key work delivery will increase in this cycle of regime planning, aligned to each establishment Regime Management Plan. Additional elements have been added to the Regime Planning Template to enable establishments in their key work delivery.” 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 additional key-work sessions for prisoners on the neurodiverse landing and during weekends in the inpatient department and Care and Separation Unit.
Verbatim wording from the response “HMP Elmley recognise that specific cohorts of prisoners are either more at risk of harm or self-harm or are more vulnerable to other incidences such as bullying. To manage this risk certain staff members have been identified and will work specifically with these cohorts, the aim being to have these staff upskilled in the areas that they are allocated to so they can help these individuals and lower the: violence, self-harm, non-compliance and bullying rates within the establishment. We currently have a member of staff from each houseblock dedicated to young offenders with the aim of increasing these dedicated cohorts over the coming months. Additional key work is also offered to those that reside on our neurodiverse landing and key work is offered each weekend within the in-patient department (IPD) and the Care and Separation Unit (CSU).” 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 Raise the minimum key-work expectation to two sessions for every prisoner every four weeks in the 2025/26 regime-planning cycle.
Verbatim wording from the response “For 2025/6 the minimum expectation for key work delivery will rise to two key work sessions every four weeks as a minimum.” 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 dedicated staff for young offenders on each houseblock to support targeted risk and vulnerability management.
Verbatim wording from the response “HMP Elmley recognise that specific cohorts of prisoners are either more at risk of harm or self-harm or are more vulnerable to other incidences such as bullying. To manage this risk certain staff members have been identified and will work specifically with these cohorts, the aim being to have these staff upskilled in the areas that they are allocated to so they can help these individuals and lower the: violence, self-harm, non-compliance and bullying rates within the establishment. We currently have a member of staff from each houseblock dedicated to young offenders with the aim of increasing these dedicated cohorts over the coming months. Additional key work is also offered to those that reside on our neurodiverse landing and key work is offered each weekend within the in-patient department (IPD) and the Care and Separation Unit (CSU).” 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 Compile HMP Elmley’s Key Work Delivery Strategy to address and improve key-work provision.
Verbatim wording from the response “Local action is also underway. The Custodial Manager who oversees keywork at HMP Elmley has been compiling a Key Work Delivery Strategy to take forward as we move into 2025. This strategy details HMP Elmley’s plan to address and improve the issue of key work within the establishment.” Source location Response from HMPPS
Open published response
Concerns raised 7 Inadequate recording and structuring of accommodation offer decisions View source Withdrawal of accommodation offers without consultation with requesting organisations View source Delays in finding CAS3 accommodation after specialist placement failure View source Unclear placement offers, conditions and expectations View source Failure of probation officers to understand accommodation availability when planning release View source Unclear access and eligibility criteria for specialist rehabilitation provision View source Lack of specialist rehabilitation accommodation for women at low or medium risk of harm to others and high risk of self-harm View source See 4 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
Kirsten Hocking · 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
Kirsten Hocking, aged 31, died in hospital on 24 May 2023 as a result of a heroin overdose after being released from prison and found in a public toilet. The concerns identified included a lack of specialist rehabilitation accommodation for some women leaving prison, training needs for probation officers arranging accommodation and release plans, and unclear placement-offer and decision-making systems at a specialist accommodation charity.
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 Inadequate recording and structuring of accommodation offer decisions
Wider context from the report “S2R started providing this kind of specialist accommodation because there was such a pressing need for more of it. They are to be welcomed for having done so. However, like many small organisations which have grown, it appears that their systems have not always grown with them. Work is already being done, but there remains a continuing risk. Placement offers and the conditions and expectations which attach to them are too unclear. The recording of decisions around offers, withdrawal, and reconsideration, also needs to be better , not just to ensure that decisions are recorded, but also to ensure that decision-making is properly structured and takes all relevant matters into account . Withdrawing accommodation offers without first speaking to the requesting organisation (in this case staff at the prison) also gives rise to risks. As this case shows, these are critically important decisions, and great care is required.
” 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 Withdrawal of accommodation offers without consultation with requesting organisations
Wider context from the report “S2R started providing this kind of specialist accommodation because there was such a pressing need for more of it. They are to be welcomed for having done so. However, like many small organisations which have grown, it appears that their systems have not always grown with them. Work is already being done, but there remains a continuing risk. Placement offers and the conditions and expectations which attach to them are too unclear. The recording of decisions around offers, withdrawal, and reconsideration, also needs to be better, not just to ensure that decisions are recorded, but also to ensure that decision-making is properly structured and takes all relevant matters into account. Withdrawing accommodation offers without first speaking to the requesting organisation (in this case staff at the prison) also gives rise to risks. As this case shows, these are critically important decisions, and great care is required.
” 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 finding CAS3 accommodation after specialist placement failure
Wider context from the report “Concern (2) is linked to the first, in that the probation officers, who have primary responsibility for finding accommodation and building release plans, need to understand what accommodation is and is not available. This case showed that no-one, including the relevant officer, realised that an AP might in theory have been available. It also showed a failure to appreciate that once the first specialist placement fell through, a second was very unlikely to be found and so CAS3 accommodation was realistically the only option. That therefore needed finding quickly, so that a support plan could be built around it . There does therefore seem to be a training need.
” 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 placement offers, conditions and expectations
Wider context from the report “S2R started providing this kind of specialist accommodation because there was such a pressing need for more of it. They are to be welcomed for having done so. However, like many small organisations which have grown, it appears that their systems have not always grown with them. Work is already being done, but there remains a continuing risk. Placement offers and the conditions and expectations which attach to them are too unclear . The recording of decisions around offers, withdrawal, and reconsideration, also needs to be better, not just to ensure that decisions are recorded, but also to ensure that decision-making is properly structured and takes all relevant matters into account. Withdrawing accommodation offers without first speaking to the requesting organisation (in this case staff at the prison) also gives rise to risks. As this case shows, these are critically important decisions, and great care is required.
” 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 probation officers to understand accommodation availability when planning release
Wider context from the report “Concern (2) is linked to the first, in that the probation officers, who have primary responsibility for finding accommodation and building release plans, need to understand what accommodation is and is not available . This case showed that no-one, including the relevant officer, realised that an AP might in theory have been available. It also showed a failure to appreciate that once the first specialist placement fell through, a second was very unlikely to be found and so CAS3 accommodation was realistically the only option. That therefore needed finding quickly, so that a support plan could be built around it. There does therefore seem to be a training need.
” 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 access and eligibility criteria for specialist rehabilitation provision
Wider context from the report “Concern (1) is that there was and remains a real lack of specialist rehabilitation for women, and in particular, women who represent only a low or medium risk of harm to others, but a high risk of self-harm. This cohort are for the most part shut out from Approved Premises (“AP”) (it appears that it is possible for medium risk women to be admitted to an AP but that possibility is not well understood and the reality is that it is not available; that kind of accommodation being very over-subscribed in any event). This means there is little or no effective system of rehabilitative provision for that cohort. This is a cohort in which the state has invested a great deal of time and money (in imprisoning and rehabilitative work) only, the evidence suggests, for that investment to be at risk of being squandered on release. It also means that provision can become dependant on small charities and related acts of individual generosity, which is patchwork and may bring problems of unclear access and unclear criteria (as happened here). The evidence was that this was being looked at by the Probation Service, which does not generally provide specialist rehabilitation accommodation itself but which has an obvious interest in it being available and so is monitoring the situation. However the evidence was also that the situation is getting worse not better, particularly for women (who tend to have higher levels of self-harm), and this is despite things like the Corston review in 2007 and the case of Voll SVJ seen later, which found discrimination because of the gender disparity with respect to the availability of APs. There is now a similar lack, and apparent gender impact, with regard to specialist rehabilitation accommodation too. The circumstances creating the risk of other deaths therefore subsist, and might benefit from some renewed focus.
” 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 specialist rehabilitation accommodation for women at low or medium risk of harm to others and high risk of self-harm
Wider context from the report “Concern (1) is that there was and remains a real lack of specialist rehabilitation for women, and in particular, women who represent only a low or medium risk of harm to others, but a high risk of self-harm . This cohort are for the most part shut out from Approved Premises (“AP”) (it appears that it is possible for medium risk women to be admitted to an AP but that possibility is not well understood and the reality is that it is not available; that kind of accommodation being very over-subscribed in any event). This means there is little or no effective system of rehabilitative provision for that cohort . This is a cohort in which the state has invested a great deal of time and money (in imprisoning and rehabilitative work) only, the evidence suggests, for that investment to be at risk of being squandered on release. It also means that provision can become dependant on small charities and related acts of individual generosity, which is patchwork and may bring problems of unclear access and unclear criteria (as happened here). The evidence was that this was being looked at by the Probation Service, which does not generally provide specialist rehabilitation accommodation itself but which has an obvious interest in it being available and so is monitoring the situation. However the evidence was also that the situation is getting worse not better, particularly for women (who tend to have higher levels of self-harm), and this is despite things like the Corston review in 2007 and the case of Voll SVJ seen later, which found discrimination because of the gender disparity with respect to the availability of APs. There is now a similar lack, and apparent gender impact, with regard to specialist rehabilitation accommodation too . The circumstances creating the risk of other deaths therefore subsist, and might benefit from some renewed focus.
” Open source report
Concerns raised 6 Inadequate first and earliest emergency response by prison officer staff View source Failure of lone prison officers to enter cells during emergencies View source Inadequate guidance and training for prison officers on emergency cell entry View source Failure to provide refresher first aid and CPR training to prison officers View source Failure to maintain unobscured cell observation panels for routine visual welfare checks View source Failure to provide prison officers with foundation first aid and CPR training View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Stephen Anthony SLEAFORD · 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
Stephen Anthony Sleaford, a prisoner at Gartree Prison, was found with a ligature around his neck in his cell on 27 October 2022 and was pronounced dead at 08:01. The concerns included inadequate first-aid and CPR training for prison officers, gaps in the earliest emergency response, obscured cell observation panels, and unclear guidance about entering cells during 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 Inadequate first and earliest emergency response by prison officer staff
Wider context from the report “3) Following the conclusion of the Inquest, I remain concerned that prison officer staff have an unrealistic expectation that prison healthcare staff will be willing and able to react timeously to any emergency unfolding , meaning there are obvious and crucial gaps in the extent and adequacy of the first/earliest response to any emergency unfolding .
” 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 lone prison officers to enter cells during emergencies
Wider context from the report “5) I am concerned that there is no, or no adequate, clear understanding by, and/or clear guidance and training provided to, prison officers around when they should enter a prison cell when it is reasonably believed that a prisoner requires immediate care or assistance due to an emergency, medical or otherwise. Evidence indicated that a ‘dynamic risk assessment’ could be undertaken by any officer who was acting/operating alone, when considering necessary and immediate entry into a cell, whereas the majority of evidence aired was that officers would ‘never’ enter a prison cell when working alone, due to fears for own safety .
” 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 guidance and training for prison officers on emergency cell entry
Wider context from the report “5) I am concerned that there is no, or no adequate, clear understanding by, and/or clear guidance and training provided to, prison officers around when they should enter a prison cell when it is reasonably believed that a prisoner requires immediate care or assistance due to an emergency, medical or otherwise. Evidence indicated that a ‘dynamic risk assessment’ could be undertaken by any officer who was acting/operating alone, when considering necessary and immediate entry into a cell, whereas the majority of evidence aired was that officers would ‘never’ enter a prison cell when working alone, due to fears for own safety.
” 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 refresher first aid and CPR training to prison officers
Wider context from the report “1) Evidence was heard that the majority of those prison officers who had commenced in their roles prior to 2018 had no first aid/basic life-saving skills and no ability/training in undertaking cardiopulmonary resuscitation (‘CPR’). Officers who had completed prison officer training between approximately April 2018 and April 2024 did have first aid training, but there had been no refresher training, subsequently, for that cohort .
2) Evidence was heard that after April 2024, basic first aid training (including CPR training) has been omitted from the foundation training programme for those training to be prison officers, meaning that NO new prison officers will have first aid/related training. I am gravely concerned that this situation (i.e. a lack of such training provided as foundation training), if it prevails, will probably lead to future deaths 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 maintain unobscured cell observation panels for routine visual welfare checks
Wider context from the report “4) The evidence revealed that despite clear instruction to officers, by way of Notices to Staff from senior management at the prison, to the effect that obscuring cell door observation panels on the inside by prisoners was not permitted practice and was to be challenged and remedied, routine practice by prison officers meant observation panels were permitted to be obscured, without challenge or sanction . This means that a situation prevailed whereby prison officers were unable to routinely see into all cells to check prisoner welfare , but were/are reliant on, and accepted, a verbal response only , which is and remains a significant concern.
” 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 prison officers with foundation first aid and CPR training
Wider context from the report “1) Evidence was heard that the majority of those prison officers who had commenced in their roles prior to 2018 had no first aid/basic life-saving skills and no ability/training in undertaking cardiopulmonary resuscitation (‘CPR’) . Officers who had completed prison officer training between approximately April 2018 and April 2024 did have first aid training, but there had been no refresher training, subsequently, for that cohort.
2) Evidence was heard that after April 2024, basic first aid training (including CPR training) has been omitted from the foundation training programme for those training to be prison officers , meaning that NO new prison officers will have first aid/related training. I am gravely concerned that this situation (i.e. a lack of such training provided as foundation training ), if it prevails, will probably lead to future deaths in prison custody.
” 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 Require operational staff to read and acknowledge the observation-panel procedure, with managers retaining records of understanding.
Verbatim wording from the response “In respect of prisoners blocking observations panels, a notice was re-issued to all staff in October 2024 reminding them of the importance of challenging prisoners who block their observation panels and setting out the process for doing so, which includes an escalation process where a prisoner continues to block their observation panel. All operational staff are now required to read and acknowledge their understanding of this process and this is retained by the respective line managers. Operational staff are also asked about their understanding of and knowledge of the correct procedure during their regular performance conversation with their line manager, as a performance expectation.” 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 Develop First Aid Awareness training videos with St John Ambulance to refresh staff understanding of first-aid procedures.
Verbatim wording from the response “Additionally, First Aid Awareness training videos have been developed by the HMPPS Health and Safety Function in conjunction with St John Ambulance as a tool to promote awareness and refresh key elements of first aid for staff, in particular those staff who do not completely refresh the Emergency First Aid or First Aid at Work certificated training packages. This is expected to be launched in November 2024.” 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 Re-issue the notice requiring staff to challenge prisoners blocking observation panels and follow the escalation process.
Verbatim wording from the response “In respect of prisoners blocking observations panels, a notice was re-issued to all staff in October 2024 reminding them of the importance of challenging prisoners who block their observation panels and setting out the process for doing so, which includes an escalation process where a prisoner continues to block their observation panel. All operational staff are now required to read and acknowledge their understanding of this process and this is retained by the respective line managers. Operational staff are also asked about their understanding of and knowledge of the correct procedure during their regular performance conversation with their line manager, as a performance expectation.” 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 Show the emergency-response film to groups of HMP Gartree staff during briefing sessions.
Verbatim wording from the response “HMPPS recently issued a new film: ‘Responding to emergency situations’, designed to help staff to understand what they need to do when they find a prisoner who has ligatured. The film has been made available to all prisons and is targeted at all staff who have face-to-face contact with prisoners, including OSGs and staff completing night duties who may need to respond to a medical emergency. All new officers are shown the film during their foundation training and HMP Gartree intends to show it to groups of staff in briefing sessions.” 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 Issue a notice reminding staff to raise medical emergency alarms, assess risks dynamically, enter cells when safe, and take immediate life-preserving action.
Verbatim wording from the response “In respect of staff response in a medical emergency, HMP Gartree has issued a Notice to Staff reminding staff of the process of unlocking a cell at night when working alone and the need to take immediate action to preserve life. Staff were reminded of the need to immediately raise the alarm by calling a medical emergency response code and inform the control room of the exact location so staff, including healthcare staff, can respond. Before entering a cell alone staff must undertake a dynamic risk assessment, which includes assessing the situation in the cell (for example if there is more than one occupant), considering the condition of the prisoner, and any risk to the safety and security of the prisoner and themselves. If they consider it is safe to do so, staff must enter the cell immediately and take action to preserve life.” 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 Re-issue the HMPPS First Aid Policy Framework nationally, including requirements for emergency first-aid training and local staffing risk assessments.
Verbatim wording from the response “The HMPPS First Aid Policy Framework was re-issued nationally in August 2023. The revised policy highlights the training requirements for Emergency First Aid and First Aid in prisons, including the importance of Governors ensuring that there is an appropriate number of trained staff on duty at all times. To achieve this, a detailed local first aid risk assessment must be produced to determine the number of First Aiders at Work (FAW) and Emergency First Aiders at work (EFAW) required at an establishment at any given period, ensuring that they are deployed appropriately.” 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 Launch the developed First Aid Awareness training videos for staff.
Verbatim wording from the response “Additionally, First Aid Awareness training videos have been developed by the HMPPS Health and Safety Function in conjunction with St John Ambulance as a tool to promote awareness and refresh key elements of first aid for staff, in particular those staff who do not completely refresh the Emergency First Aid or First Aid at Work certificated training packages. This is expected to be launched in November 2024.” 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 Issue the film ‘Responding to emergency situations’ nationally to help prison staff respond when prisoners have ligatured.
Verbatim wording from the response “HMPPS recently issued a new film: ‘Responding to emergency situations’, designed to help staff to understand what they need to do when they find a prisoner who has ligatured. The film has been made available to all prisons and is targeted at all staff who have face-to-face contact with prisoners, including OSGs and staff completing night duties who may need to respond to a medical emergency. All new officers are shown the film during their foundation training and HMP Gartree intends to show it to groups of staff in briefing sessions.” 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 Check operational staff understanding of the observation-panel procedure during regular performance conversations as a performance expectation.
Verbatim wording from the response “In respect of prisoners blocking observations panels, a notice was re-issued to all staff in October 2024 reminding them of the importance of challenging prisoners who block their observation panels and setting out the process for doing so, which includes an escalation process where a prisoner continues to block their observation panel. All operational staff are now required to read and acknowledge their understanding of this process and this is retained by the respective line managers. Operational staff are also asked about their understanding of and knowledge of the correct procedure during their regular performance conversation with their line manager, as a performance expectation.” 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 Reinforce medical-emergency response requirements through wing briefings and the Governor’s full staff briefing.
Verbatim wording from the response “In addition to the Notice to Staff, the requirements above will be reiterated via wing briefings and during the Governor’s full staff briefing.” Source location Response from HMPPS
Open published response
9 Sep 2024 Ian William Deavall · Prevention of Future Deaths report Greater Manchester West
View report summary
Concerns raised 2 Risk of non-VP prisoners victimising VP prisoners View source Failure of emergency cell bells to remain operable and alert prison staff View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Ian William Deavall · 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
Ian William Deavall, who had ischaemic heart disease and hypotension, suffered a cardiac arrest in his cell at HMP Forest Bank on 24 January 2023. The emergency cell bell was deactivated by another prisoner, cancelling the alert in the wing office and removing the only indication of the exact cell, so staff became aware of the emergency more by accident than design. The report identifies an ongoing risk because emergency cell bells can still be readily deactivated by other prisoners and no fail-safe measures are currently proposed.
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 Risk of non-VP prisoners victimising VP prisoners
Wider context from the report “(1) The response to a medical emergency will generally be time critical.
(2) The risk that non-VP prisoners will victimise VP prisoners is a recognised one.
(3) That prison staff became aware of the medical emergency in the Deceased’s case was more by accident than design (depending as it did on the caprice of Prisoner A).
There remains a risk that future deaths could occur as it remains the case that emergency cell bells at HMP Forest Bank can be deactivated readily and altogether by other prisoners and no action to implement fail-safe measures is currently proposed.
” 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 emergency cell bells to remain operable and alert prison staff
Wider context from the report “(1) The response to a medical emergency will generally be time critical.
(2) The risk that non-VP prisoners will victimise VP prisoners is a recognised one.
(3) That prison staff became aware of the medical emergency in the Deceased’s case was more by accident than design (depending as it did on the caprice of Prisoner A).
There remains a risk that future deaths could occur as it remains the case that emergency cell bells at HMP Forest Bank can be deactivated readily and altogether by other prisoners and no action to implement fail-safe measures is currently proposed .
” 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 Separate vulnerable and non-vulnerable prisoners across two induction wings.
Verbatim wording from the response “HMP Forest Bank has advised that the induction is now split across two wings, which allows VPs and non-VPs to be housed separately, which means that the risks to VPs associated with co-location, including the cancelling of cell call bells by non-VPs, are no longer present.” Source location Response from HMPPS
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 Separating vulnerable and non-vulnerable prisoners means the risks associated with their co-location, including bell cancellation, are no longer present.
Verbatim wording from the response “HMP Forest Bank has advised that the induction is now split across two wings, which allows VPs and non-VPs to be housed separately, which means that the risks to VPs associated with co-location, including the cancelling of cell call bells by non-VPs, are no longer present.” Source location Response from HMPPS
Open published response
7 Aug 2024 Kevin John McDonnell · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 4 Failure of prison staff to read and understand the July 2021 annex to PSI 64/2011 View source Failure to secure and retain accurate documentary evidence following a death in custody View source Failure to conduct meaningful and purposeful ACCT observations and conversations View source Failure to share risk pertinent information with all staff caring for a prisoner 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
Kevin John McDonnell · 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
Kevin John McDonnell was discovered deceased in his prison cell on 29 September 2022, having died by ligature asphyxiation; the inquest concluded that he had died by suicide. The principal concerns included failures to conduct planned ACCT reviews and checks, share identified suicide-risk information, provide necessary mental-health support, and preserve accurate documentary evidence after 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 Failure of prison staff to read and understand the July 2021 annex to PSI 64/2011
Wider context from the report “2. Prison staff have not read and understood the July 2021 annex to PSI 64/2011 . There was a failure to share risk pertinent information about Kevin to all staff caring for him that day.
” 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 and retain accurate documentary evidence following a death in custody
Wider context from the report “3. Failure to secure and retain documentary evidence following a death in custody . If post-death investigations are misled by inaccurate documentation that has been amended post-death , then the ability to learn from deaths in custody will be hampered. The preservation of accurate documentary evidence must be of paramount concern when a person dies in 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 conduct meaningful and purposeful ACCT observations and conversations
Wider context from the report “1. Prison staff were unfamiliar with the need for ACCT observations and conversations to be meaningful and have purpose . Witnesses repeatedly described these checks as simply “proof of life” checks . One witness gave the example of an ACCT observation being completed simply by hearing a noise from within the cell or observing the prisoner collecting his lunch from two landings above. Such cursory observations of prisoners at risk of suicide and self-harm is inconsistent with the aims and objectives of the ACCT PSI (64/2021).
” 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 share risk pertinent information with all staff caring for a prisoner
Wider context from the report “2. Prison staff have not read and understood the July 2021 annex to PSI 64/2011. There was a failure to share risk pertinent information about Kevin to all staff caring for him that day .
” 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 Increase and continue SASH/ACCT awareness training and refresher upskilling for staff.
Verbatim wording from the response “HMPPS is committed to ensuring that all staff are equipped with the necessary skills and knowledge to perform their role effectively and safely. I have been informed by the Governor of HMP Nottingham that the prison have increased their delivery of SASH/ACCT awareness and upskilling via training days and one-to-one refresher sessions, resulting in a greater number of staff being trained in these areas. The prison will continue to offer ACCT training and upskilling sessions to all staff to increase these numbers further.” 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 Keep ACCT books on the wing during quality assurance checks so staff can make contemporaneous entries.
Verbatim wording from the response “The matter of accurate documentary evidence being secured following a death in custody is something that I take extremely seriously. I am satisfied that the actions taken by staff in this instance were not malicious or done with the intention of misleading any investigation or enquiry. Nevertheless, this was not best practice and I understand that ACCT books are no longer taken” 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 a trigger database accessible to all staff to share pertinent risk information about individuals in crisis.
Verbatim wording from the response “In respect of information sharing, the Governor informs me that HMP Nottingham have introduced a ‘trigger’ database which contains any important/pertinent information that may impact on an individual’s risk. This database is accessible to all staff and enables the sharing of information specific to those in crisis ensuring they are supported during this time.” Source location Response from HM Prison and Probation Service
Open published response
Concerns raised 2 Failure of probation oversight to ensure awareness and proper administration of mental health treatment requirements View source Failure to transfer and communicate mental health treatment requirements to receiving Trusts 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
Lee Spencer PURKIS · 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
Lee Purkis, aged 54, was found in an advanced state of decomposition on the floor of his home on 9 March 2023, having been there for up to two months; the cause of death was unascertainable. Before his death, he was subject to a mental health treatment requirement, but the receiving Trust was not informed of it and discharged him without learning about it. The report identifies a risk that failures to transfer or oversee such requirements could affect their proper administration in other cases.
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 probation oversight to ensure awareness and proper administration of mental health treatment requirements
Wider context from the report “My concern here is that Lee Purkis had been, in the period leading up to his death, the subject of a mental health treatment requirement (MHTR) imposed by the Crown Court as part of a community order, but the Trust that ended up treating him were not aware of it, and discharged him from its care without learning about it. There is no evidence that it made any difference in this case but that is because of the particular (and unfortunate) circumstances of how long it took to find Mr Purkis and the corresponding absence of evidence about how he died. There is, however, a real risk that it might make a difference in another case. This order was handed down by a sympathetic Crown Court judge, supported by probation in the pre-sentence report, and it seems to have been a potentially creative solution for a complex man. The use of MHTRs is, it seems to me on the evidence, to be encouraged, but that objective will be undermined if they are not understood and administered properly and so people don’t see them working. In Mr Purkis’s case, the particular problem appears to have occurred because the Trust that agreed the order (a requirement of it being imposed in the first place) then transferred the care because the accommodation area changed. That is not unusual, but the relevant Trust then failed to transfer or inform the receiving Trust of the fact of the MHTR and what it required. This means that it was, of course, a Trust error, but I am sending this report to probation because the evidence suggests that it is probation that should have oversight, and it should be ensuring all involved in the administration of the requirement are aware of it . I therefore consider there is a risk associated with these circumstances, and that action should be taken, such as ensuring that probation officers keep an eye on MHTRs when they have them, and ensure the other services do so too . There are not many of them; there probably should be more; but again, that means ensuring the ones that there are get used properly.
” 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 transfer and communicate mental health treatment requirements to receiving Trusts
Wider context from the report “My concern here is that Lee Purkis had been, in the period leading up to his death, the subject of a mental health treatment requirement (MHTR) imposed by the Crown Court as part of a community order, but the Trust that ended up treating him were not aware of it, and discharged him from its care without learning about it . There is no evidence that it made any difference in this case but that is because of the particular (and unfortunate) circumstances of how long it took to find Mr Purkis and the corresponding absence of evidence about how he died. There is, however, a real risk that it might make a difference in another case. This order was handed down by a sympathetic Crown Court judge, supported by probation in the pre-sentence report, and it seems to have been a potentially creative solution for a complex man. The use of MHTRs is, it seems to me on the evidence, to be encouraged, but that objective will be undermined if they are not understood and administered properly and so people don’t see them working. In Mr Purkis’s case, the particular problem appears to have occurred because the Trust that agreed the order (a requirement of it being imposed in the first place) then transferred the care because the accommodation area changed. That is not unusual, but the relevant Trust then failed to transfer or inform the receiving Trust of the fact of the MHTR and what it required . This means that it was, of course, a Trust error, but I am sending this report to probation because the evidence suggests that it is probation that should have oversight, and it should be ensuring all involved in the administration of the requirement are aware of it. I therefore consider there is a risk associated with these circumstances, and that action should be taken, such as ensuring that probation officers keep an eye on MHTRs when they have them, and ensure the other services do so too. There are not many of them; there probably should be more; but again, that means ensuring the ones that there are get used properly.
” Open source report
1 Aug 2024 Leah Shannon Croucher · Prevention of Future Deaths report Milton Keynes
View report summary
Concerns raised 2 Failure to adequately monitor sex offenders in the community View source Failure to share information between agencies supervising sex offenders 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
Leah Shannon Croucher · 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
Leah Shannon Croucher left home to walk to work on 15 February 2019 but did not arrive, and her body was found in a Milton Keynes house in October 2022. The inquest concluded that she was unlawfully killed. The report raises concerns about the supervision of a known repeat sex offender and information sharing between the police and probation service.
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 adequately monitor sex offenders in the community
Wider context from the report “Leah Croucher was unlawfully killed by a man who was subject to supervision by the probation service and the police. Despite that supervision he was in breach of the terms of his probation and was able to kill Leah when it was known that he was a predator and danger to females. There should be a fundamental review of the process for monitoring sex offenders in the community and the sharing of information between all agencies particularly the police and probation service to ensure that a similar death can be prevented.
” 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 share information between agencies supervising sex offenders
Wider context from the report “Leah Croucher was unlawfully killed by a man who was subject to supervision by the probation service and the police. Despite that supervision he was in breach of the terms of his probation and was able to kill Leah when it was known that he was a predator and danger to females. There should be a fundamental review of the process for monitoring sex offenders in the community and the sharing of information between all agencies particularly the police and probation service to ensure that a similar death can be prevented.
” Open source report
1 Aug 2024 Matthew Paul Braben · Prevention of Future Deaths report West London
View report summary
Concerns raised 6 Prisoners being kept in their cells for up to 23 hours a day View source Failure to ensure the ACCT post-closure process is followed after moves to another location View source Gym instructor training arrangements creating significant disincentives for staff to train View source Insufficient training of staff in the ACCT process View source Failure to recognise the birth of a child as a specific mental-health risk factor View source Shortage of gym instructors View source See 3 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
Matthew Paul Braben · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Matthew Paul Braben died by asphyxia at HMP Wormwood Scrubs on 16 August 2021 after being found in his cell with his neck, wrists and ankles tied. The report identified concerns including failures to identify and respond to suicide risk, inadequate communication and record-keeping, failures relating to ACCT processes, and the impact of prisoners being held in their cells for up to 23 hours a day.
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 Prisoners being kept in their cells for up to 23 hours a day
Wider context from the report “4. Prisoners being kept in their cells for up to 23 hours a day , with a negative effect on their mental health .
” 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 the ACCT post-closure process is followed after moves to another location
Wider context from the report “2. The robustness of the process for ensuring that the ACCT post-closure process is followed , particularly following a move to another location .
” 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 Gym instructor training arrangements creating significant disincentives for staff to train
Wider context from the report “5. The manner of training of gym instructors which entails potential trainees having to attend training at a distant location for significant period of times rather than locally as well as the length of the course , both of which serve as significant disincentives for staff to be trained as gym instructors . The shortage of gym instructors leads directly to more prisoners being kept in their cells for up to 23 hours a day, with a negative effect on their mental health.
” 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 training of staff in the ACCT process
Wider context from the report “3. Training of staff in the ACCT process .
” 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 the birth of a child as a specific mental-health risk factor
Wider context from the report “1. The birth of a child is not recognised as a specific risk factor in PSI 64/2011 which means that staff may under-estimate its significance on mental health .
” 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 Shortage of gym instructors
Wider context from the report “5. The manner of training of gym instructors which entails potential trainees having to attend training at a distant location for significant period of times rather than locally as well as the length of the course, both of which serve as significant disincentives for staff to be trained as gym instructors. The shortage of gym instructors leads directly to more prisoners being kept in their cells for up to 23 hours a day , with a negative effect on their mental health.
” Open source report
26 Jul 2024 Zara Natasha Aleena · Prevention of Future Deaths report East London
View report summary
Concerns raised 25 Failure to provide prison risk intelligence to Integrated Offender Management meetings View source Threshold for reflective practice set too high View source Unclear understanding of when to request emergency recall View source Lack of mandatory and refreshed risk assessment training View source Lack of supervision for prison offender managers View source Failure to examine local intelligence and Computer Aided Dispatch systems in sufficient detail View source Lack of systems to support staff supervising key decisions View source Lack of alerts for handover from prison to community offender managers View source Lack of checks on sharing up-to-date and accurate risk assessments View source Failure of prison offender managers to implement sentence plans and facilitate rehabilitation View source Lack of focused risk assessment training for prison offender managers View source Lack of rigour, detail and independence in MPS investigations View source Unclear and incomplete sharing of risk information between probation and the MPS View source Failure to conduct timely risk assessments with complementary risk management plans View source Societal acceptance of unreported following behaviour View source Unclear CCTV operator training on identifying sexual predators and stalking behaviour View source Lack of assurance and refresher training for CCTV operators View source Failure to holistically assess indicators of serious harm View source Failure of alert systems to highlight restraining orders View source Lack of reporting guidance and training for business owners on sexualised or predatory behaviour View source OASYS risk assessment tool failing to support extraction and analysis of key risk areas View source Understaffing of probation delivery units View source Failure to probe information relevant to risk View source Obstacles inhibiting increases in assessed risk levels View source Failure of prison offender managers to gather and share evidence relevant to risk formulation View source See 22 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Zara Natasha Aleena · 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
Zara Natasha Aleena died at the Royal London Hospital on 26 June 2022 after sustaining a severe traumatic brain injury during an unprovoked attack while walking home in Ilford. The report identifies concerns about understaffing, risk assessment, information sharing, supervision, recall procedures and coordination across the Probation Service, police and other agencies, as well as concerns about training and reporting of predatory behaviour.
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 prison risk intelligence to Integrated Offender Management meetings
Wider context from the report “(15)The Integrated Offender Management meetings did not receive the necessary intelligence from the prison setting . There was no system in place to ensure that either the prison offender manager was invited to attend, or that the prison offender manager was asked to provide written information around risk incidents .
” 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 Threshold for reflective practice set too high
Wider context from the report “(18)There were clearly learning points for the police constables, police sergeants and the local intelligence team. The MPS rejected the DPS recommendation for reflective learning, “as there was no failing in performance or conduct”. It is of concern that the threshold for reflective practice is set too high .
” 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 understanding of when to request emergency recall
Wider context from the report “(10) The evidence revealed a difference of opinion and understanding around when an emergency recall should be requested . A senior probation officer and probation services officer erroneously believed that an emergency recall could only be requested out of hours .
” 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 and refreshed risk assessment training
Wider context from the report “(4) Risk assessment training is not part of the mandatory training framework within the probation service. Risk assessment training is not refreshed .
” 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 supervision for prison offender managers
Wider context from the report “(12)There was no evidence that the prison offender manager from February 2021 to October 2021 paid any attention to the sentence plan in place for the offender. They did not attempt to facilitate any rehabilitative interventions. There was no evidence of supervision for the prison offender manager .
” 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 examine local intelligence and Computer Aided Dispatch systems in sufficient detail
Wider context from the report “(17)The Fast Time Review did not probe into sufficient detail into the systems of the local intelligence team and the Computer Aided Dispatch process . A more detailed, independent review should have been carried out.
” 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 systems to support staff supervising key decisions
Wider context from the report “(2) There were no systems in place devised to assist the staff working in these stretched circumstances , such as easy reference checklists for supervising key decisions .
” 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 alerts for handover from prison to community offender managers
Wider context from the report “(13)There was no system in place to alert the prison offender manager to handover an offender to the community offender manager when a period of sentence ended and where the offender remained in prison, on remand.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Lack of checks on sharing up-to-date and accurate risk assessments
Wider context from the report “(5) There were no checks to ensure the provision of up to date and accurate risk assessments to partner agencies (such as the housing team).
” 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 offender managers to implement sentence plans and facilitate rehabilitation
Wider context from the report “(12)There was no evidence that the prison offender manager from February 2021 to October 2021 paid any attention to the sentence plan in place for the offender . They did not attempt to facilitate any rehabilitative interventions . There was no evidence of supervision for the prison offender manager.
” 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 focused risk assessment training for prison offender managers
Wider context from the report “(11) The role of the prison offender manager is to gather evidence to assist with the formulation of risk. Prison offender managers do not however receive focussed risk assessment training . Neither of the prison offender managers in this case gathered evidence to assist with the formulation of risk. There were multiple intelligence logs and records that should have been obtained by them. The logs included findings of possession of weapons, drug taking, threats to harm others and a sustained assault on a servery worker using an improvised weapon. This information was not gathered and shared appropriately.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Lack of rigour, detail and independence in MPS investigations
Wider context from the report “(16)I am concerned about the lack of rigour, detail and independence of the MPS investigation into this case. The unit involved in this case was the East Area BCU. An independent, rapid investigation (Fast Time Review) was carried out by the Directorate of Professional Standards. Despite the very limited time to complete the review, the DPS officer reached clear and valuable findings. The findings of the DPS investigator were however rejected by more senior officers within the MPS. The officers who rejected the findings were not independent and all worked within the East Area BCU. This lack of independence is of concern.
” 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 and incomplete sharing of risk information between probation and the MPS
Wider context from the report “(14)The system in place for sharing risk information between the probation service and the MPS was unclear . Only very limited intelligence was shared with the MPS . There was no explanation as to why that information was shared, when more concerning risk related information was not shared .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct timely risk assessments with complementary risk management plans
Wider context from the report “(3) The understanding around risk assessment was poor , at all levels of staffing. The practical application of risk assessment was poor at all levels of staffing. Risk was not assessed at appropriate times , and the assessment of risk was not accompanied by a complementary risk management plan . Risk management plans were once prepared before risk was fully assessed (as occurred with the setting of licence conditions). One practitioner was advised to set a risk level to match other completed documents (without analysis of risk itself). Practitioners did not holistically assess risk and take account of potential indicators of serious harm, to include use of weapons; attitudes supportive of violence; callousness and high increased frequency of lower-level violence.
” 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 Societal acceptance of unreported following behaviour
Wider context from the report “(21) At least two other members of the public were followed by the offender before he attacked Zara Aleena. The members of the public appear to have seen the offender and appear to be aware that he was following them. This was not brought to the attention of the emergency services. I am concerned that there is a societal acceptance that such conduct does not need to be reported .
” 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 CCTV operator training on identifying sexual predators and stalking behaviour
Wider context from the report “(19)The details of training for CCTV operators includes “training on sexual harassment”, but it is not clear whether this includes identifying sexual predators and stalking type behaviour .
” 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 assurance and refresher training for CCTV operators
Wider context from the report “(20)I am unclear from the evidence provided, whether LBR have a system for checking that training provided to CCTV operators is fully understood , or whether refresher training is provided to 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 Failure to holistically assess indicators of serious harm
Wider context from the report “(3) The understanding around risk assessment was poor, at all levels of staffing. The practical application of risk assessment was poor at all levels of staffing. Risk was not assessed at appropriate times, and the assessment of risk was not accompanied by a complementary risk management plan. Risk management plans were once prepared before risk was fully assessed (as occurred with the setting of licence conditions). One practitioner was advised to set a risk level to match other completed documents (without analysis of risk itself). Practitioners did not holistically assess risk and take account of potential indicators of serious harm , to include use of weapons; attitudes supportive of violence; callousness and high increased frequency of lower-level violence.
” 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 alert systems to highlight restraining orders
Wider context from the report “(8) The globe system and alert systems did not work effectively in this case. A restraining order had been put in place against the offender, but this was not highlighted , as it should have been. Key staff involved in assessing and managing the offender were unaware of the restraining order .
” 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 reporting guidance and training for business owners on sexualised or predatory behaviour
Wider context from the report “(22)Business owners were aware of the offender’s concerning conduct on the night of Zara Aleena’s murder. For example, a public house had refused to provide more drinks to him. It is not clear whether business owners are encouraged to report such concerning behaviour to the authorities or whether they are offered any training to assist them and their staff to recognise sexualised or predatory behaviour .
” 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 OASYS risk assessment tool failing to support extraction and analysis of key risk areas
Wider context from the report “(7) The OASYS risk assessment tool is unwieldy and difficult to navigate . It was challenging to extract the most relevant material. The content of the OASYS assessment was so dense that the probation officers seemed to get lost in the detail and failed to pull together and formulate/analyse key risk areas . One senior probation officer stated that she would not look at the OASYS when allocating cases, because OASYS assessments were “not always accurate and up to date”. It is noted that a new risk assessment tool within the probation service is a work in progress. It is hoped that the new tool will take into account the above concerns.
” 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 Understaffing of probation delivery units
Wider context from the report “(1) The probation delivery unit responsible for the offender was understaffed at the time of relevant oversight. The staffing levels were 61% in 2022 . The staffing levels at the time of the inquest in June 2024 was 58% . The inquest heard that this is a national problem and that there are other probation delivery units that have even lower levels of staffing. The low staffing level had an impact upon quality and depth of assessments; quality of supervision of junior staff (supervision was wholly reactive); excessively high workloads for probation officers and senior probation officers; lack of cover during annual leave for probation officers and poor record keeping.
” 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 probe information relevant to risk
Wider context from the report “(6) There was a lack of professional curiosity and a lack of sufficient probing into information relevant to 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 Obstacles inhibiting increases in assessed risk levels
Wider context from the report “(9) There may be obstacles to increasing risk levels . The inquest heard that senior probation staff would have to approve increases in risk. As staffing levels are so stretched, there may be reticence of junior probation officers to trouble the senior team . The risk assessment policy also includes a statement that staff “should not use risk levels to inflate risk because of anxiety or to access resources”. It is a concern that this provision may inhibit decisions to increase 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 Failure of prison offender managers to gather and share evidence relevant to risk formulation
Wider context from the report “(11) The role of the prison offender manager is to gather evidence to assist with the formulation of risk. Prison offender managers do not however receive focussed risk assessment training. Neither of the prison offender managers in this case gathered evidence to assist with the formulation of risk . There were multiple intelligence logs and records that should have been obtained by them . The logs included findings of possession of weapons, drug taking, threats to harm others and a sustained assault on a servery worker using an improvised weapon. This information was not gathered and shared appropriately .
” 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 Deliver further risk-assessment training events for practitioners responsible for managing people in the community.
Verbatim wording from the response “3.4. The structured process of risk assessment as set out in the RoSH Guidance, if followed, supports staff to think about an individual’s behaviour holistically, not just the index offence; and make reflective, logical, and informed decisions about risk. The section on risk management provides a structure to produce risk management plans that address the identified risks and set actions to protect people at risk.” Source location Response from HMPPS and MoJ
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 Apply the Prioritisation Framework in understaffed probation delivery units and operate its refreshed version alongside Probation Reset.
Verbatim wording from the response “1.1. We accept that the Probation Delivery Unit (PDU) responsible for Jordan McSweeney was understaffed at the time. Whilst at a national level, the staffing position of the Probation Service is improving, I acknowledge that raising staffing in this PDU to its full complement remains a significant challenge. Therefore, until such time as the situation improves, in this PDU and others with acute pressure remaining, staff will follow a Prioritisation Framework which we first implemented in January 2022. Those PDUs will also benefit from wider national workload relief through Probation Reset (see below at 1.4) as reflected in a refreshed Prioritisation Framework published in May 2024.” Source location Response from HMPPS and MoJ
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 the mandated Information Sharing Form to standardise information sharing between prisons and community colleagues for short-term prisoners.
Verbatim wording from the response “15.1. We acknowledge that prison staff did not share intelligence about ████████ ████████ with their colleagues in the Probation Service. We have agreed processes in place to ensure that prisons communicate information to the COM for sentenced prisoners, but these processes did not function properly in this case, as explained in the SFO review. For long-term prisoners, information sharing from the POM to the COM occurs at point of handover. In November 2023, we standardised expectations for those prisoners serving a short-term custodial sentence.” Source location Response from HMPPS and MoJ
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 the statement discouraging risk-level inflation during the next risk-assessment policy review.
Verbatim wording from the response “9.1. We do not have any evidence of a widespread problem of Probation Officers being reluctant to ask SPOs to approve formal increases in assessed risk, or that this particular statement in policy is inhibiting staff from raising their assessment of an offender’s risk level, where that would be justified based on the available evidence. The percentage of those assessed as ‘high risk of serious harm’ has increased in recent years from 19.9% in 2018 to 25% in 2022. PARG’s annual sentence management audit confirms agreement with the risk level in most assessments. To avoid any misinterpretation, this statement will be removed in the next review, due by November.” Source location Response from HMPPS and MoJ
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 practice guidance on recording Civil Orders and adding or removing globe alerts.
Verbatim wording from the response “8.3. We will review practice guidance by December 2024, including when to add and remove a globe to ensure that HMPPS staff are clear on the need to record Civil Orders. We are also committed to a review of the globe system by March 2025 with the purpose streamlining and to make information more accessible to staff. We are committed to identifying whether digital solutions are available to improve the review, updating and termination of information on the globe system. However, this will have multi-system impacts and will need to be embedded alongside other changes as systems are developed, rather than be progressed in isolation. This will impact on timescales for this aspect of the solution.” Source location Response from HMPPS and MoJ
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 Remind London probation staff about emergency recalls during normal working hours and repeat the reminder for SDS40 implementation.
Verbatim wording from the response “10.1. We accept that there was an inconsistency in understanding of emergency recall processes in this case. All London Probation staff have been reminded of the availability of the emergency recall process during normal working hours. Another reminder was given to all staff in preparation for SDS40 (the recent changes to standard determinate sentences, announced in July and implemented in September 2024).” Source location Response from HMPPS and MoJ
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 Implement the Human Factors decision-making model in two further regions and evaluate and review the model and its products.
Verbatim wording from the response “2.4. Our work on Human Factors recognises the broader components of decision making and the importance of creating an environment that enables individuals and the wider organisation to learn from error. Human Factors aims to reduce the frequency and severity of mistakes by using mechanical or digital overrides or prompts and/or by introducing tools and techniques such as checklists as preventative measures. Work in Wales Probation (2022-2024), based on Human Factors, tested a model designed to assist practitioners (which can include Probation Service Officers, Trainee Probation Officers and qualified Probation Officers), Senior Probation Officers and operational leaders with managing priorities and decision making, with a key emphasis on risk.” Source location Response from HMPPS and MoJ
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 globe system and identify digital solutions to improve accessibility, updating and termination of Civil Order information.
Verbatim wording from the response “8.3. We will review practice guidance by December 2024, including when to add and remove a globe to ensure that HMPPS staff are clear on the need to record Civil Orders. We are also committed to a review of the globe system by March 2025 with the purpose streamlining and to make information more accessible to staff. We are committed to identifying whether digital solutions are available to improve the review, updating and termination of information on the globe system. However, this will have multi-system impacts and will need to be embedded alongside other changes as systems are developed, rather than be progressed in isolation. This will impact on timescales for this aspect of the solution.” Source location Response from HMPPS and MoJ
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 Continue developing tools to support probation risk-management practice.
Verbatim wording from the response “2.3. To assist with everyday operational process and procedure, Probation Practitioners have access to a comprehensive system known as EQUiP (Excellence & Quality in Process), which contains guidance and process maps for most of the operational decision-making and is continuously updated to reflect changes to policy, tasks and timings. Alongside this, HMPPS continues to develop a range of tools to support risk management practice.” Source location Response from HMPPS and MoJ
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 Put in place a clear national Management Oversight and first-tier assurance framework for community and custody work.
Verbatim wording from the response “9.3. In response to an HMIP Thematic Report on The Role of the Senior Probation Officer and Management Oversight published in January 2024, a number of initiatives across the Probation Service are underway exploring the role of the Senior Probation Officer and aiming to improve capacity and capability to undertake that role. As part of this, by December 2024, HMPPS will put in place a clear Policy Framework for Management Oversight and first-tier assurance. This will meet the demands of the probation caseload and ensure that effective management oversight arrangements are in place at the regional and Probation Delivery Unit level to assure the quality of work to protect the public by February 2025.” Source location Response from HMPPS and MoJ
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 mandatory professional registration for Probation Officers to strengthen continuing development, performance and accountability.
Verbatim wording from the response “5.1. We accept that in this case up to date and accurate assessments of ████████
████████’s risk were not shared with partner agencies. We are committed to improving professional standards of practice and have introduced mandatory professional registration for Probation Officers, which aims to sharpen focus on Continuous Professional Development and drive improved performance and personal accountability to deliver public protection. Whilst managers do oversee Probation Officer work, we would not expect them to check every referral before it is made. The professional standards will, alongside increased staffing levels and improved digital checks/safeguards, ensure that Probation Officers do all that is required of them, including the sharing of risk information with partner agencies, whose contribution is vital to the efficacy of risk management plans.” Source location Response from HMPPS and MoJ
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 Work with Ministry of Justice digital colleagues to streamline the current OASys tool ahead of ARNS rollout.
Verbatim wording from the response “7.7. ARNS is one of a number of tools being developed across HMPPS and the Criminal Justice System (CJS) to the current shared government digital standards which will, in time, allow better flow of information from one to another and therefore will support better information sharing. We are prioritising digital resource for the development of ARNS. However, ahead of its full roll out, HMPPS will work in partnership with Ministry of Justice digital colleagues to streamline the current OASys tool where it is possible to do so efficiently and in a way that supports, rather than detracts, from the development of ARNS.” Source location Response from HMPPS and MoJ
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, pilot and launch the Continuing Professional Development risk-learning product for experienced practitioners.
Verbatim wording from the response “4.4. Experienced Probation Practitioners are required to revisit and complete their training in relation to Child Safeguarding and Domestic Abuse on a three-year cycle. Knowledge and understanding of risk assessment and management are further developed through experience of the work and its supervision. However, historically there has not been a requirement to attend further formal training on risk assessment and management. Having recognised that risk practice is not consistently at a sufficient standard, in December 2023 a new Continuing Professional Development risk learning product was commissioned to address this gap. This is intended to enable experienced practitioners to explore in-depth concepts related to risk assessment and to ensure their practice knowledge is up to date.” Source location Response from HMPPS and MoJ
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 and roll out the ARNS digital assessment and sentence-planning service with supporting staff learning.
Verbatim wording from the response “7.4. More broadly, we are investing in the Assessing Risks, Needs and Strengths (ARNS) project, the replacement for OASys to be used in prisons and by the Probation Service. The project aims to deliver a transformational change in how we assess offenders, using the latest international evidence, including that on criminal desistance. In addition to a new enabling digital service for assessment and sentence planning, there is a comprehensive new learning and development offer to support staff to adapt and enhance their practice. The roll-out of ARNS is scheduled to begin in the third quarter of 2025 and be in place fully by the third quarter of 2026.” Source location Response from HMPPS and MoJ
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 Probation Reset measures to prioritise early engagement and end eligible supervision after two-thirds of the licence or order period.
Verbatim wording from the response “1.4. As well as the focus on recruitment, in response to the additional demands placed on the Probation Service as a result of measures to address prison capacity, since July 2024 we have implemented a set of measures known as Probation Reset. These measures involve prioritising early engagement at the point where offenders are most likely to breach the requirements of their licence or community sentence and, in eligible cases, end active supervision of offenders after two-thirds of the licence or community order period. In turn, this ensures that staff can maximise the amount of available supervision time on the most serious offenders. Early indications show that Probation Reset has brought capacity into the system and workloads to more manageable levels.” Source location Response from HMPPS and MoJ
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 London processes, practices and operating models to identify a refined approach for managing acute pressures and caseloads.
Verbatim wording from the response “2.2. As outlined in response to concern (1), whilst Probation Reset has provided us with a workload reduction, the need to prioritise work and make effective decisions remain central to what we require of probation staff. In accordance with the Prioritisation Framework, Probation Regions are assigned a red, amber, or green categorisation depending upon the degree of prioritisation required. This Framework was reviewed in June 2024 to reflect Probation Reset, given the implications for operational delivery. London Probation moved to the Prioritisation Framework at its outset in 2022. London is operating within red/amber site status, which is regularly reviewed. Alongside this, there is a specific project being run by the London Area Executive Director to review processes and practices alongside operating models.” Source location Response from HMPPS and MoJ
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 Deliver the Civil Order e-learning package and complete relevant staff training by the target date.
Verbatim wording from the response “8.2. To further strengthen practice and ensure that practitioners do not miss the significance of a restraining order or any other Civil Order, in May 2024 we released a new Civil Order e-learning package to provide HMPPS staff with an overview and awareness of Civil and ancillary Orders and why they are important in probation work. Our target is that all staff in relevant roles will have completed this by the end of March 2025.” Source location Response from HMPPS and MoJ
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 Require Prison Offender Managers to be invited to all Integrated Offender Management pre-release case conferences or provide written updates when absent.
Verbatim wording from the response “15.2. To ensure that all appropriate agencies involved in an Integrated Offender Management (IOM) case are included in any pre-release work, the National IOM” Source location Response from HMPPS and MoJ
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 Continue national recruitment and trainee recruitment to increase Probation Practitioner staffing and maintain a pipeline of qualified officers.
Verbatim wording from the response “1.2. We continue to prioritise recruitment to put the Service on a sustainable footing and ensure sufficient Probation Practitioner staffing (Probation Officers and Probation Service Officers). As of 30 June 2024, the staffing level of Probation Officers working across the Probation Service was 70%, with 5,136 Full Time Equivalent (FTE) Probation Officers in post. This number shows a considerable increase relative to June 2021 (when Community Rehabilitation Companies were dissolved, and the Probation Service was unified) when we had 4,517 FTE Probation Officers in post. London had the highest vacancy rate of all regions as of 30 June 2024 with a vacancy rate of 41%.” Source location Response from HMPPS and MoJ
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 Prompt OASys assessors to identify Civil Orders and incorporate their implications into risk assessment and management.
Verbatim wording from the response “8.1. We recognise the importance of probation staff being aware of restraining orders and they are expected to record them in a globe in the case record system (i.e., an alert) with the start and end date, with explanatory notes. We also recognise that the globe system requires staff to look for and record relevant information. To ensure that staff are expected to consider whether there is a restraining order and to use the information to inform the management of the case, in April 2023 HMPPS made a change to the OASys tool to prompt assessors to state if people under their supervision are subject to Civil Orders. This means that practitioners are supported to include behaviours which have resulted in the courts imposing a Civil Order in their risk assessment even if they were not convicted of an offence.” Source location Response from HMPPS and MoJ
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 Deliver revised risk-assessment training to new practitioners and introduce new training for experienced staff.
Verbatim wording from the response “3.3. As set out in our response to His Majesty’s Inspectorate of Probation Serious Further Offence Review, the RoSH Guidance is based on the right evidence, including learning from Serious Further Offence Reviews and Domestic Homicide Reviews, but there are ongoing organisational challenges in its implementation. We are taking steps to address the barriers to its effectiveness, but we know there is more to do, and we will publish a new HMPPS Public Protection Strategy by the end of March 2025. We have already made changes to the suite of risk training which all new learners on the Probation qualification route and new Probation Service Officers complete.” Source location Response from HMPPS and MoJ
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 community offender manager remains responsible for recalled prisoners and must monitor sentence expiry dates and close the record.
Verbatim wording from the response “13.1. If a prisoner’s status is remand only, there is no statutory responsibility for supervision as the prisoner is unsentenced. If a prisoner is subject to both remand and recall, they are subject to statutory supervision only to the point of the Sentence Expiry Date. All recalled prisoners remain the responsibility of the Community Offender Manager (COM). The Prison Offender Manager is not expected to handover the supervision of the case, as the COM is responsible throughout. It is the responsibility of the COM to monitor the sentence expiry dates, as they will need to complete a termination OASys and close the record.” Source location Response from HMPPS and MoJ
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 There is no evidence of a widespread reluctance to seek approval for increased risk or that the policy statement inhibits justified risk escalation.
Verbatim wording from the response “9.1. We do not have any evidence of a widespread problem of Probation Officers being reluctant to ask SPOs to approve formal increases in assessed risk, or that this particular statement in policy is inhibiting staff from raising their assessment of an offender’s risk level, where that would be justified based on the available evidence. The percentage of those assessed as ‘high risk of serious harm’ has increased in recent years from 19.9% in 2018 to 25% in 2022. PARG’s annual sentence management audit confirms agreement with the risk level in most assessments. To avoid any misinterpretation, this statement will be removed in the next review, due by November.” Source location Response from HMPPS and MoJ
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 Areas, regions and prisons are responsible for overseeing practice and ensuring prison offender managers perform their duties.
Verbatim wording from the response “12.2. HMPPS sets national standards and operating models centrally, but it is down to areas/regions/prisons to oversee practice and ensure that POMs are carrying out their duties and tasks accordingly.” Source location Response from HMPPS and MoJ
Open published response
11 Jun 2024 Yuri Hatton · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 4 Failure of first aid training to be prison specific for recognising unconsciousness View source Lack of official training for Operational Support Grades View source Failure to centrally record and monitor first aid training View source Failure to implement induction training on responding to suspected prisoner unconsciousness 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
Yuri Hatton · 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
Yuri Hatton, who was detained at HMP Wandsworth, died in hospital on 9 November 2018 after being found unresponsive following a suspected opiate overdose and later showing features of brain stem death. The jury identified four failures that cumulatively possibly contributed to his death, including failures involving emergency response, clinical observations and communications. The report also raised concerns about limited OSG training, the frequency and monitoring of first aid training, and the lack of prison-specific training on recognising unconsciousness.
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 first aid training to be prison specific for recognising unconsciousness
Wider context from the report “(3) Recognising unconsciousness. The First Aid training offered, whilst addressing unconsciousness, is not prison specific . A new induction package was said to be rolled out imminently which will include instructions about what a member of prison staff should do if they believe that a prisoner could be unconscious and will reiterate the instruction to call a code blue in such circumstances. This training has not yet been implemented.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Lack of official training for Operational Support Grades
Wider context from the report “(1) Operational Support Grade (OSG) training. Following the Inquest, I sought further evidence regarding several matters, including OSG training. A statement provided by HMP Wandsworth confirms that of 83 OGSs, only 5 had received HMPPS official training . This is against the background of OSG’s only being present on the wings at night, and therefore often the first to respond to any emergency.
” 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 centrally record and monitor first aid training
Wider context from the report “(2) The frequency and monitoring of first aid training. First Aid training is said to be refreshed locally annually. Training logs of some staff members involved in the Inquest did not show centrally all the training received , instead a local training log is said to be kept, but which were absent at the inquest or post-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 implement induction training on responding to suspected prisoner unconsciousness
Wider context from the report “(3) Recognising unconsciousness. The First Aid training offered, whilst addressing unconsciousness, is not prison specific. A new induction package was said to be rolled out imminently which will include instructions about what a member of prison staff should do if they believe that a prisoner could be unconscious and will reiterate the instruction to call a code blue in such circumstances. This training has not yet been implemented .
” Open source report
31 May 2024 Frazer Charlie Williams · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 17 Lack of guidance on transferring prisoners under healthcare-team care between establishments View source Lack of national guidance for management and operational staff on pre-transfer prisoner handover View source Lack of consultation with receiving-prison healthcare teams about care capability View source Lack of national guidance for healthcare handover to receiving prisons View source Failure to deliver the keyworker scheme in line with national guidance View source Lack of process for recording and involving prisoners’ next of kin View source Lack of NHS and joint HMPPS guidance on identifying, managing and treating self-neglect in prisons View source Delays in transferring prisoners requiring mental health hospital admission View source Lack of a national directory of healthcare facilities and provision at individual prisons View source Lack of guidance requiring consultation with prison doctors before transferring prisoners receiving medical care View source Lack of automatic flagging of missed ACCT reviews View source Lack of ACCT quality assurance between day 7 and post-closure review View source Failure to make an immediate ambulance call when a code blue or red is raised View source Failure to invite relevant individuals such as key workers to ACCT reviews View source Lack of national specification for prison healthcare units View source Failure of the email-a-prisoner system to facilitate contact after unrecognised prisoner transfers View source Camouflaging similarity between cell-door and bedsheet colours View source See 14 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Frazer Charlie Williams · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Frazer Charlie Williams was found deceased on 7 March 2022 in his cell at HMP Guys Marsh, suspended by a ligature. The report identifies concerns about delays transferring prisoners requiring mental health hospital care, inadequate arrangements for managing self-neglect and healthcare handovers, shortcomings in ACCT monitoring and reviews, and other prison care and safety processes. The inquest concluded that he died by suicide in circumstances where there was inadequate assessment and monitoring of his risks of self-harm and suicide prior to his death.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on transferring prisoners under healthcare-team care between establishments
Wider context from the report “iii. There is a lack of a national directory detailing the facilities and provision of healthcare at individual prisons across England and Wales, and associated guidance on the transfer of individuals between prison establishments when they are under the care of the healthcare teams and are not placed on medical hold . There is a lack of guidance on consultation with prison doctors where a prisoner is receiving medical care, whether that be for physical or mental health, when there is consideration by the prison to transfer the prisoner who is not placed on medical hold. Further there is a lack of consultation with the healthcare team at the proposed receiving prison to ensure they can provide the appropriate care for the person.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidance for management and operational staff on pre-transfer prisoner handover
Wider context from the report “vi. There is lack of national guidance for both senior management and operational prison staff in relation to the handover of a prisoner in advance of their transfer , not specific to, but especially those with complex needs, when transferring between prisons.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Lack of consultation with receiving-prison healthcare teams about care capability
Wider context from the report “iii. There is a lack of a national directory detailing the facilities and provision of healthcare at individual prisons across England and Wales, and associated guidance on the transfer of individuals between prison establishments when they are under the care of the healthcare teams and are not placed on medical hold. There is a lack of guidance on consultation with prison doctors where a prisoner is receiving medical care, whether that be for physical or mental health, when there is consideration by the prison to transfer the prisoner who is not placed on medical hold. Further there is a lack of consultation with the healthcare team at the proposed receiving prison to ensure they can provide the appropriate care for the person .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidance for healthcare handover to receiving prisons
Wider context from the report “iv. There is a lack of national guidance for healthcare teams working in prisons around the handover of healthcare of a prisoner to the receiving prison when they are transferred to another prison.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to deliver the keyworker scheme in line with national guidance
Wider context from the report “x. The keyworker scheme is not being delivered in line with national guidance at HMP Guys Marsh.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Lack of process for recording and involving prisoners’ next of kin
Wider context from the report “xiii. There is a lack of process regarding the recording of a prisoner’s next of kin and involvement of them at HMP Guys Marsh.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Lack of NHS and joint HMPPS guidance on identifying, managing and treating self-neglect in prisons
Wider context from the report “ii. There is a lack of NHS guidance, and joint guidance with HMPPS, on the identification, management, and treatment of someone with self neglect in the prison setting .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Delays in transferring prisoners requiring mental health hospital admission
Wider context from the report “i. There is inequity within the system of the treatment of a person with mental illness in the prison setting compared to an individual in the community, due to the fact that in the community a person would be placed in a hospital setting on the day they were deemed to require hospital admission, however in prison there are delays in transferring a prisoner in the same situation to hospital .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Lack of a national directory of healthcare facilities and provision at individual prisons
Wider context from the report “iii. There is a lack of a national directory detailing the facilities and provision of healthcare at individual prisons across England and Wales , and associated guidance on the transfer of individuals between prison establishments when they are under the care of the healthcare teams and are not placed on medical hold. There is a lack of guidance on consultation with prison doctors where a prisoner is receiving medical care, whether that be for physical or mental health, when there is consideration by the prison to transfer the prisoner who is not placed on medical hold. Further there is a lack of consultation with the healthcare team at the proposed receiving prison to ensure they can provide the appropriate care for the person.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance requiring consultation with prison doctors before transferring prisoners receiving medical care
Wider context from the report “iii. There is a lack of a national directory detailing the facilities and provision of healthcare at individual prisons across England and Wales, and associated guidance on the transfer of individuals between prison establishments when they are under the care of the healthcare teams and are not placed on medical hold. There is a lack of guidance on consultation with prison doctors where a prisoner is receiving medical care , whether that be for physical or mental health, when there is consideration by the prison to transfer the prisoner who is not placed on medical hold . Further there is a lack of consultation with the healthcare team at the proposed receiving prison to ensure they can provide the appropriate care for the person.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Lack of automatic flagging of missed ACCT reviews
Wider context from the report “viii. There is lack of automatic flagging of a missed ACCT review at HMP Guys Marsh and this could also be a national problem.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Lack of ACCT quality assurance between day 7 and post-closure review
Wider context from the report “vii. The lack of ACCT quality assurance, or audit, between day 7 of the ACCT and the post closure review .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to make an immediate ambulance call when a code blue or red is raised
Wider context from the report “xii. PSI 03/2013 is not being followed at HMP Guys Marsh as there is no immediate call to the ambulance service when a code blue or red is raised .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to invite relevant individuals such as key workers to ACCT reviews
Wider context from the report “ix. Relevant individuals, such as key workers are not being invited to attend ACCT reviews at HMP Guys Marsh in line with ACCT 6 guidance.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Lack of national specification for prison healthcare units
Wider context from the report “v. There is a lack of national specification in respect of prison healthcare units .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure of the email-a-prisoner system to facilitate contact after unrecognised prisoner transfers
Wider context from the report “xiv. The email a prisoner system is dependant on the person wanting to contact the prisoner knowing their location , so if the prisoner is transferred to another prison and the person contacting them is not aware, contact which can be a protective factor particularly in a prisoner’s mental health care, will not be facilitated.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Camouflaging similarity between cell-door and bedsheet colours
Wider context from the report “xi. The colour of the cell doors and bedsheets at HMP Guys Marsh, and possibly at other prisons nationally, being very similar can camouflage ligatures .
” Open source report
Concerns raised 2 Failure to provide timely training and guidance on the appropriate use of Code Blue and Code Red communications during a medical emergency View source Failure to provide timely training and guidance on entering a cell during a medical emergency View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Luke Mikael PEARCE · 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 Pearce was found hanging in his cell at HMP/YOI Swinfen Hall on 6 April 2023 and was pronounced dead after staff and paramedics performed CPR. The report identified delays in entering the cell, removing the ligature and starting CPR, and raised concerns that relevant emergency training and guidance, including the use of Code Blue and Code Red communications, was not being delivered to appropriate staff in a timely manner.
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 timely training and guidance on the appropriate use of Code Blue and Code Red communications during a medical emergency
Wider context from the report “That relevant training and guidance to equip staff to understand when and how to enter a cell in a medical emergency, and the appropriate use of Code Blue and Code Red communications in a medical emergency , is not being delivered in a timely manner to appropriate 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 provide timely training and guidance on entering a cell during a medical emergency
Wider context from the report “That relevant training and guidance to equip staff to understand when and how to enter a cell in a medical emergency , and the appropriate use of Code Blue and Code Red communications in a medical emergency, is not being delivered in a timely manner to appropriate staff .
” 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 guidance on emergency response procedures to staff every six months.
Verbatim wording from the response “of HMP/YOI Swinfen Hall’s local training programme, staff will be trained to understand when it is appropriate and necessary to enter a cell during patrol state and guidance on emergency response procedures will be issued to staff every 6 months.” Source location Response from HMPPS/YOI Swinfen Hall
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 Show the emergency response video annually to all staff.
Verbatim wording from the response “I have received assurance from the Governor of HMP/YOI Swinfen Hall that the emergency response training video is being shown to all existing members of staff as part of their Safety Critical training, with the view for this to be achieved by March 2025. Going forward, HMP/YOI Swinfen Hall will also ensure that the video is shown annually to all staff.” Source location Response from HMPPS/YOI Swinfen Hall
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 Show the emergency response video to all existing staff through Safety Critical training.
Verbatim wording from the response “I have received assurance from the Governor of HMP/YOI Swinfen Hall that the emergency response training video is being shown to all existing members of staff as part of their Safety Critical training, with the view for this to be achieved by March 2025. Going forward, HMP/YOI Swinfen Hall will also ensure that the video is shown annually to all staff.” Source location Response from HMPPS/YOI Swinfen Hall
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 Brief staff at the beginning of night duty on Code Blue, Code Red and entering cells during medical emergencies, with Safety and Security quality assurance checks.
Verbatim wording from the response “Additionally, Custodial Managers have been instructed to brief all staff at the beginning of night duty about the use of Code Blue and Code Red and entering cells in a medical emergency, which will be subject to quality assurance checks by both the Safety and Security departments. As part” Source location Response from HMPPS/YOI Swinfen Hall
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 the emergency response video available to staff and deliver it through foundation training for new officers.
Verbatim wording from the response “During the inquest, evidence was heard concerning the new national video that was launched in January 2024. The video includes a demonstration on how staff should respond to an emergency situation, which includes instructions on when to enter a cell in an emergency and the appropriate use of Code Blue and Code Red communications. This video has been made available to all HMPPS staff, including Officer Support Grades (OSGs) and staff completing night duties who may need to respond to a medical emergency. Since January 2024, the video has been delivered to all new officers via foundation training and has been shared locally with Governing Governors.” Source location Response from HMPPS/YOI Swinfen Hall
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 Train staff through the local programme on when entering a cell during patrol state is appropriate and necessary.
Verbatim wording from the response “of HMP/YOI Swinfen Hall’s local training programme, staff will be trained to understand when it is appropriate and necessary to enter a cell during patrol state and guidance on emergency response procedures will be issued to staff every 6 months.” Source location Response from HMPPS/YOI Swinfen Hall
Open published response
13 Mar 2024 Jacob Michael Nicholas BILLINGTON · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 5 Failure to record prisoners’ GP and CMHT details in an easily accessible format View source Failure to establish effective information sharing for prison discharge coordination View source Lack of cross-agency provisions and guidance for release planning of high-risk prisoners with mental health difficulties View source Unclear responsibilities and case remit for the prison discharge coordinator role View source Failure to coordinate interagency release management and share critical information 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
Jacob Michael Nicholas BILLINGTON · 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
Jacob Michael Nicholas Billington was unlawfully killed when he was stabbed in the neck during a night out in Birmingham on 6 September 2020. The concerns included inadequate coordination and information-sharing between agencies during the release of a high-risk prisoner with serious mental health difficulties, and a lack of clear cross-agency guidance and understanding of responsibilities.
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 prisoners’ GP and CMHT details in an easily accessible format
Wider context from the report “2. Sysmone Details of the perpetrators GP and local CMHT were not recorded in an easily accessible format. The format in which key information is recorded has now been amended at HMP Swansea to ensure the prisoner’s GP details and their CMHT’s details (if a person is an existing patient under a CMHT) are highlighted on a front screen/page. I was informed that this change in information management and presentation within Sysmone is unique to HMP Swansea and is not the practice in other prisons. I am concerned that there remains a risk that staff treating patients in prison may not have easy access to (and so overlook) this key information.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to establish effective information sharing for prison discharge coordination
Wider context from the report “4. West Midlands MAPPA has a prison discharge coordinator role. It was clear from the evidence at the inquest that this role was not fully understood by other agencies and what information needed to be shared was not clear. The new policy drafted by BSMHT remained confused as to which cases were to fall within the responsibility of the prison discharge coordinator role. There remains a risk of further deaths as the role is not properly understood and information sharing is not effective.
” 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 cross-agency provisions and guidance for release planning of high-risk prisoners with mental health difficulties
Wider context from the report “3. Cross agency guidance regarding release of high risk prisoners with mental health difficulties at their sentence end date. There are no provisions available nor any cross agency guidance in place for when a high-risk prisoner is released at sentence end date to ensure that there is adequate release planning and maximum support in the community.
” 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 responsibilities and case remit for the prison discharge coordinator role
Wider context from the report “4. West Midlands MAPPA has a prison discharge coordinator role. It was clear from the evidence at the inquest that this role was not fully understood by other agencies and what information needed to be shared was not clear. The new policy drafted by BSMHT remained confused as to which cases were to fall within the responsibility of the prison discharge coordinator role. There remains a risk of further deaths as the role is not properly understood and information sharing is not effective.
” 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 interagency release management and share critical information
Wider context from the report “1. Management of release and lack of interagency working. The management of the perpetrators release was not coordinated and there was inadequate communication between relevant agencies. In effect agencies worked in silos. Critical information is not being shared and agencies work in different IT systems meaning there is no one place where information is collated and hence a comprehensive account of matters known to each agency is not easily available to those professionals who may need to know a high risk prisoner’s whereabouts on release. This concern was reinforced by evidence heard during the inquest that changes made since Jacob's death did not include the resettlement information being given to Mental Health In reach teams in the prison. The failure to share information leads to a concern of future deaths as high risk seriously unwell prisoners may be released without key agencies knowing where they are meaning any are not traced and treated assertively in the community.
” 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 NHS Reconnect Service to probation practitioners to support referrals for through-the-gate transition support.
Verbatim wording from the response “NHS-England are commissioned to provide healthcare in Prisons. The sharing of information between health in custody and health in the community is a core feature of the nationally rolled out NHS-England Reconnect Service. West Midlands Probation Service has actively promoted the Reconnect Service with Probation Practitioners in recent months to ensure they are aware of how to refer into this service in Prison for support “through the gate”, the transition period from prison into the community.” 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 Revise and reissue the sentence-end-date release practice document, and embed its expectations in staff development sessions.
Verbatim wording from the response “For a prisoner to still be detained in custody at the point of sentence expiry is usually as a result of them having been recalled to custody. This means they remain the responsibility of the Probation Community Offender Manager (COM) until the point of release at the sentence end date (SED). There is no statutory authority for Probation supervision of a prisoner released into the community at SED. The sharing of information prior to release into the community in an effective manner with relevant agencies is therefore of paramount importance. The Probation Service West Midlands has a practice document which sets out the expectations for Practitioners when cases are being released at SED. This document has been revised and reissued to all staff and embedded in development sessions delivered by the Regional Quality Team.” 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 Continue reviewing and refining MAPPA practices to improve interagency working and risk-information sharing.
Verbatim wording from the response “MAPPA arrangements are overseen by a Strategic Management Board (SMB) and in the West Midlands this Board will continue to review and refine practices to ensure interagency working is effective and to support the sharing of relevant risk information. The findings in this case have been presented to MAPPA SMB. The SMB is committed to ensuring their part in providing avenues to share information. Furthermore, the SMB has reinforced the statutory requirement for all duty to cooperate agencies in the MAPPA arena.” 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 Work with the Health Trust on guidance revisions for the prison discharge coordinator role to clarify responsibilities, information sharing and probation-service implementation.
Verbatim wording from the response “The Prison Discharge Coordinator role is a Health Trust bespoke role in Birmingham and Solihull. West Midlands Probation Service welcomes the investment in this role for this area and will work with the Health Trust to support any Guidance revisions undertaken by the Health Trust to ensure that the Guidance is clear and enables effective information sharing and can be embedded within and understood by all in the Probation Service.” 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 Reinforce the statutory information-sharing requirement for MAPPA duty-to-cooperate agencies.
Verbatim wording from the response “MAPPA arrangements are overseen by a Strategic Management Board (SMB) and in the West Midlands this Board will continue to review and refine practices to ensure interagency working is effective and to support the sharing of relevant risk information. The findings in this case have been presented to MAPPA SMB. The SMB is committed to ensuring their part in providing avenues to share information. Furthermore, the SMB has reinforced the statutory requirement for all duty to cooperate agencies in the MAPPA arena.” 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 HMPPS cannot access, review or change SystmOne because it is an information system used by healthcare professionals.
Verbatim wording from the response “Systmone is an IT system used by healthcare professionals, and is not a system that HMPPS can access, review or change.” 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 The Health Trust is responsible for revising guidance for the prison discharge coordinator role; Probation will support that work.
Verbatim wording from the response “The Prison Discharge Coordinator role is a Health Trust bespoke role in Birmingham and Solihull. West Midlands Probation Service welcomes the investment in this role for this area and will work with the Health Trust to support any Guidance revisions undertaken by the Health Trust to ensure that the Guidance is clear and enables effective information sharing and can be embedded within and understood by all in the Probation Service.” 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 Probation has no statutory authority to supervise prisoners released into the community at sentence expiry.
Verbatim wording from the response “For a prisoner to still be detained in custody at the point of sentence expiry is usually as a result of them having been recalled to custody. This means they remain the responsibility of the Probation Community Offender Manager (COM) until the point of release at the sentence end date (SED). There is no statutory authority for Probation supervision of a prisoner released into the community at SED. The sharing of information prior to release into the community in an effective manner with relevant agencies is therefore of paramount importance. The Probation Service West Midlands has a practice document which sets out the expectations for Practitioners when cases are being released at SED. This document has been revised and reissued to all staff and embedded in development sessions delivered by the Regional Quality Team.” Source location Response from HMPPS
Open published response
12 Mar 2024 Giuseppe TABONE and Andrew EVANS · Prevention of Future Deaths report East Sussex
View report summary
Concerns raised 5 Confusion about when full prisoner roll checks are required View source Insufficient monitoring of staff completion of required prisoner checks View source Failure by staff to understand the importance of completing every required roll check View source Failure to carry out required prisoner roll checks View source Inaccurate recording of prisoner roll checks View source See 2 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
Giuseppe TABONE and Andrew EVANS · 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
Giuseppe Tabone and Andrew Evans died at HMP Lewes after intentionally inhaling isotonitazene, a synthetic opioid. Prison staff failed to carry out required roll checks at 7.30pm and 8.45pm on 27 June 2022, and the report raises concerns about staff compliance with, understanding of, and monitoring of required prisoner checks.
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 Confusion about when full prisoner roll checks are required
Wider context from the report “At the inquest, two prison staff admitted that they had independently failed to carry out the required roll checks on L wing at 7.30pm and 8.45pm on the evening of 27 June 2022. One officer recorded on the wing log book that he had carried out the 7.30pm check, even though he did not do so. The other gave evidence that he did not carry out the 8.45pm check because he was distracted by the day shift officers, who were watching videos in the control room and were not responding to prisoner's cell bell calls. The staff members concerned have been subject to disciplinary proceedings, but continue to work at the prison. It was not possible to say on the evidence whether Andrew or Giuseppe’s lives could have been saved had the required roll checks been carried out. Evidence was given that, since this incident, staff have been provided with ‘bite size’ training on roll checks, although neither of the staff members concerned had received this training.
I remain concerned that there is a risk of future deaths caused by prison staff at HMP Lewes failing to carry out the required checks on prisoners, particularly during the night state. The purpose of roll checks is to ensure that each prisoner is present and alive and well. If a roll check is not carried out, there is a risk that a prisoner in need of medical attention and unable to ring the cell bell could remain undiscovered until the morning. There was confusion from staff at the prison as to when full roll checks are required. Further, I am concerned that staff may know when roll checks are required but not fully understand the importance of carrying out every required check. Both staff members concerned were aware that the roll check was required, but did not carry it out because they thought that checks had been carried out by other staff members. I am also concerned that there are insufficient measures in place to monitor staff to ensure that all required checks are being carried out. There may be lessons that can be learnt from other prisons as to how to ensure checks are always carried out.
” 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 monitoring of staff completion of required prisoner checks
Wider context from the report “At the inquest, two prison staff admitted that they had independently failed to carry out the required roll checks on L wing at 7.30pm and 8.45pm on the evening of 27 June 2022. One officer recorded on the wing log book that he had carried out the 7.30pm check, even though he did not do so. The other gave evidence that he did not carry out the 8.45pm check because he was distracted by the day shift officers, who were watching videos in the control room and were not responding to prisoner's cell bell calls. The staff members concerned have been subject to disciplinary proceedings, but continue to work at the prison. It was not possible to say on the evidence whether Andrew or Giuseppe’s lives could have been saved had the required roll checks been carried out. Evidence was given that, since this incident, staff have been provided with ‘bite size’ training on roll checks, although neither of the staff members concerned had received this training.
I remain concerned that there is a risk of future deaths caused by prison staff at HMP Lewes failing to carry out the required checks on prisoners, particularly during the night state. The purpose of roll checks is to ensure that each prisoner is present and alive and well. If a roll check is not carried out, there is a risk that a prisoner in need of medical attention and unable to ring the cell bell could remain undiscovered until the morning. There was confusion from staff at the prison as to when full roll checks are required. Further, I am concerned that staff may know when roll checks are required but not fully understand the importance of carrying out every required check. Both staff members concerned were aware that the roll check was required, but did not carry it out because they thought that checks had been carried out by other staff members. I am also concerned that there are insufficient measures in place to monitor staff to ensure that all required checks are being carried out . There may be lessons that can be learnt from other prisons as to how to ensure checks are always carried out.
” 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 by staff to understand the importance of completing every required roll check
Wider context from the report “At the inquest, two prison staff admitted that they had independently failed to carry out the required roll checks on L wing at 7.30pm and 8.45pm on the evening of 27 June 2022. One officer recorded on the wing log book that he had carried out the 7.30pm check, even though he did not do so. The other gave evidence that he did not carry out the 8.45pm check because he was distracted by the day shift officers, who were watching videos in the control room and were not responding to prisoner's cell bell calls. The staff members concerned have been subject to disciplinary proceedings, but continue to work at the prison. It was not possible to say on the evidence whether Andrew or Giuseppe’s lives could have been saved had the required roll checks been carried out. Evidence was given that, since this incident, staff have been provided with ‘bite size’ training on roll checks, although neither of the staff members concerned had received this training.
I remain concerned that there is a risk of future deaths caused by prison staff at HMP Lewes failing to carry out the required checks on prisoners, particularly during the night state. The purpose of roll checks is to ensure that each prisoner is present and alive and well. If a roll check is not carried out, there is a risk that a prisoner in need of medical attention and unable to ring the cell bell could remain undiscovered until the morning. There was confusion from staff at the prison as to when full roll checks are required. Further, I am concerned that staff may know when roll checks are required but not fully understand the importance of carrying out every required check . Both staff members concerned were aware that the roll check was required, but did not carry it out because they thought that checks had been carried out by other staff members . I am also concerned that there are insufficient measures in place to monitor staff to ensure that all required checks are being carried out. There may be lessons that can be learnt from other prisons as to how to ensure checks are always carried out.
” 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 prisoner roll checks
Wider context from the report “At the inquest, two prison staff admitted that they had independently failed to carry out the required roll checks on L wing at 7.30pm and 8.45pm on the evening of 27 June 2022. One officer recorded on the wing log book that he had carried out the 7.30pm check, even though he did not do so. The other gave evidence that he did not carry out the 8.45pm check because he was distracted by the day shift officers, who were watching videos in the control room and were not responding to prisoner's cell bell calls. The staff members concerned have been subject to disciplinary proceedings, but continue to work at the prison. It was not possible to say on the evidence whether Andrew or Giuseppe’s lives could have been saved had the required roll checks been carried out. Evidence was given that, since this incident, staff have been provided with ‘bite size’ training on roll checks, although neither of the staff members concerned had received this training.
I remain concerned that there is a risk of future deaths caused by prison staff at HMP Lewes failing to carry out the required checks on prisoners, particularly during the night state . The purpose of roll checks is to ensure that each prisoner is present and alive and well. If a roll check is not carried out, there is a risk that a prisoner in need of medical attention and unable to ring the cell bell could remain undiscovered until the morning . There was confusion from staff at the prison as to when full roll checks are required. Further, I am concerned that staff may know when roll checks are required but not fully understand the importance of carrying out every required check. Both staff members concerned were aware that the roll check was required, but did not carry it out because they thought that checks had been carried out by other staff members. I am also concerned that there are insufficient measures in place to monitor staff to ensure that all required checks are being carried out. There may be lessons that can be learnt from other prisons as to how to ensure checks are always carried out.
” 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 Inaccurate recording of prisoner roll checks
Wider context from the report “At the inquest, two prison staff admitted that they had independently failed to carry out the required roll checks on L wing at 7.30pm and 8.45pm on the evening of 27 June 2022. One officer recorded on the wing log book that he had carried out the 7.30pm check, even though he did not do so. The other gave evidence that he did not carry out the 8.45pm check because he was distracted by the day shift officers, who were watching videos in the control room and were not responding to prisoner's cell bell calls. The staff members concerned have been subject to disciplinary proceedings, but continue to work at the prison. It was not possible to say on the evidence whether Andrew or Giuseppe’s lives could have been saved had the required roll checks been carried out. Evidence was given that, since this incident, staff have been provided with ‘bite size’ training on roll checks, although neither of the staff members concerned had received this training.
I remain concerned that there is a risk of future deaths caused by prison staff at HMP Lewes failing to carry out the required checks on prisoners, particularly during the night state. The purpose of roll checks is to ensure that each prisoner is present and alive and well. If a roll check is not carried out, there is a risk that a prisoner in need of medical attention and unable to ring the cell bell could remain undiscovered until the morning. There was confusion from staff at the prison as to when full roll checks are required. Further, I am concerned that staff may know when roll checks are required but not fully understand the importance of carrying out every required check. Both staff members concerned were aware that the roll check was required, but did not carry it out because they thought that checks had been carried out by other staff members. I am also concerned that there are insufficient measures in place to monitor staff to ensure that all required checks are being carried out. There may be lessons that can be learnt from other prisons as to how to ensure checks are always carried out.
” 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 Publish staff notices reinforcing the importance of completing roll checks and prompting key safety observations.
Verbatim wording from the response “I am also informed that the prison has published notices to staff highlighting the importance of carrying out roll checks in line with expectations. A notice to staff was issued in August 2023 which prompts staff to consider three points when carrying out roll checks:” 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 on-the-job roll-check support and training through standards coaching team staff shadowing officers at HMP Lewes.
Verbatim wording from the response “I can confirm that HMP Lewes has planned further sessions of ‘bite size’ training on roll checks. The two members of staff who gave evidence that they had not received the training will be required to attend as a priority. Additionally, the prison has received support from the standards coaching team, a national resource, which consisted of a team of experienced prison staff shadowing officers at HMP Lewes to provide support and on-the-job training. The team covered roll checks as part of the support.” 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 Issue a staff notice communicating learning from the inquest about roll checks after the review is complete.
Verbatim wording from the response “Following the inquest into the deaths of Mr Tabone and Mr Evans, the prison is reviewing roll checks to ensure that processes are in line with new staffing profiles and regime planning which is currently being reviewed and updated. Once this work is complete, a new notice to staff will be issued setting out learning from the inquest around roll checks.” 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 Continue taking appropriate action, including disciplinary action where necessary, when staff fail to meet roll-check expectations.
Verbatim wording from the response “Staff are aware that CCTV is in use around the establishment and that their actions may be scrutinised following an incident such as a death in custody. If staff are found to have failed to carry out the required tasks or when there is a question over their performance and ability there will be a thorough investigation to determine what has happened and to ensure that staff who fail to uphold the values of HMPPS by putting prisoner’s safety at risk are held to account through disciplinary procedures. Staff are aware that failure to carry out the duties entrusted to them will result in disciplinary action, and that, depending on the circumstances, the outcome may range from advice and guidance in order to support them to perform better, to dismissal from the service.” 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 Review and clarify the roll-check local operating procedure, including required times and recording arrangements.
Verbatim wording from the response “The Governor of HMP Lewes has informed me that the prison’s LOP on roll checks was reviewed in August 2023 and clearly sets out the times that roll checks are required to be carried out and where staff must sign to confirm that the checks have been completed. The LOP provides guidance on checks during the week, on weekends and during the night state so that staff understand what their duties are at all times.” 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 further bite-size roll-check training sessions, prioritising staff who previously lacked the training.
Verbatim wording from the response “I can confirm that HMP Lewes has planned further sessions of ‘bite size’ training on roll checks. The two members of staff who gave evidence that they had not received the training will be required to attend as a priority. Additionally, the prison has received support from the standards coaching team, a national resource, which consisted of a team of experienced prison staff shadowing officers at HMP Lewes to provide support and on-the-job training. The team covered roll checks as part of the support.” 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 Review the roll-check process against new staffing profiles and regime planning.
Verbatim wording from the response “Following the inquest into the deaths of Mr Tabone and Mr Evans, the prison is reviewing roll checks to ensure that processes are in line with new staffing profiles and regime planning which is currently being reviewed and updated. Once this work is complete, a new notice to staff will be issued setting out learning from the inquest around roll checks.” 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 Existing roll-check assurance measures and staff accountability are considered sufficient; staff must be trusted to perform required duties.
Verbatim wording from the response “I understand that evidence was given at the inquest on the assurance measures in place for roll checks at the prison but that you remain concerned that the measures are insufficient. Whilst I am also concerned to learn of instances where staff have not carried out their duties in line with clear expectations, we must be able to trust staff to carry out the required tasks that are fundamental to their role. HMP Lewes also holds a daily briefing which provides an opportunity to update and remind staff of the duties to be carried out as well as to convey any other important information.” Source location Response from HM Prison and Probation Service
Open published response
5 Feb 2024 Liam Turner · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 1 Lack of mandatory in-date basic first aid training for prison officers 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
Liam Turner · 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
Liam Turner died at HMP Manchester on 6 December 2021 from mixed toxicity involving a psychoactive substance and prescription medication. Concerns were raised that prison officers were not required to have in-date basic first aid training, including CPR, and that 48% of HMP Manchester prison staff had expired training certification.
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 mandatory in-date basic first aid training for prison officers
Wider context from the report “It is not mandatory for prison officers to have basic first aid training (which includes the provision of CPR) which is in-date. Once a prison officer’s three-year period has expired, whilst they may be reminded by the prison establishment that their certification is no longer live, it is not mandatory for them to renew this. For example, at HMP Manchester, at present 52% of prison staff received Emergency First Aid at Work (EFAW) training within the past three years as part of their initial officer training. Therefore, 48% of prison staff will have training certification (which includes CPR) which has expired. The evidence admitted was that the main reason for this is due to it not being mandatory for prison staff to have up-to-date training.
” 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 conducting regular reviews to ensure first-aid staffing and healthcare provision meet the prison’s needs.
Verbatim wording from the response “At HMP Manchester, the requirement is for the provision of 21 trained first aiders and there are currently 39 officers with in-date training. Further to this, 52% of prison staff have received EFAW training within the last three years as part of their initial officer training. This is in addition to the provision of healthcare, which at HMP Manchester is 24 hours a day, 7 days a week, in line with the Category A status of the prison. As such, healthcare staff are able to provide emergency assistance should the need arise. Regular reviews will continue to be conducted to ensure that the needs of the prison are met.” 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 policy framework with requirements for emergency and prison first-aid training and appropriate staffing.
Verbatim wording from the response “As you are aware, the HMPPS First Aid Policy Framework was re-issued nationally in August 2023. The revised policy highlights the training requirements for Emergency First Aid and First Aid in prisons, including the importance of Governors ensuring that there is an appropriate number of trained staff on duty at all times. To achieve this, a detailed local first aid risk assessment must be produced to determine the number of First Aiders at Work (FAW) and Emergency First Aiders at Work (EFAW) required at an establishment at any given period, ensuring that they are deployed appropriately.” 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 Existing first-aid staffing, training, healthcare provision and CPR guidance are considered sufficient to address concerns about emergency medical responses.
Verbatim wording from the response “As you are aware, the HMPPS First Aid Policy Framework was re-issued nationally in August 2023. The revised policy highlights the training requirements for Emergency First Aid and First Aid in prisons, including the importance of Governors ensuring that there is an appropriate number of trained staff on duty at all times. To achieve this, a detailed local first aid risk assessment must be produced to determine the number of First Aiders at Work (FAW) and Emergency First Aiders at Work (EFAW) required at an establishment at any given period, ensuring that they are deployed appropriately.” Source location Response from HM Prison and Probation Service
Open published response
17 Jan 2024 Kane Christopher Boyce · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 10 Failure to implement learning from investigations following deaths in custody View source Unclear and potentially inaccurate Early Learning Review investigation methodology View source Failure to control the deliberate ignoring of prisoner cell bells View source Lack of policy governing the isolation of power to cells View source Failure to follow the Under the Influence Policy View source Poor quality Early Learning Review failing to identify safety issues and learning View source Lack of understanding and training on key dates or anniversaries as self-harm risk factors View source Failure to recognise the ACCT threshold without a verbalised self-harm statement View source Failure to make agreed factual admissions of shortcomings during death in custody inquests View source Lack of a culture of candour and staff reflection after deaths in custody View source See 7 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
Kane Christopher Boyce · 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
Kane Christopher Boyce, a serving prisoner at HMP Lowdham Grange, was found with a ligature around his neck on 3 October 2021 and could not be resuscitated. The jury found that alcohol intoxication and the failure of staff to share information, open an under-the-influence log, adequately monitor him, and consider risk when isolating cell power and ignoring cell bells contributed to his death. The report raised concerns about these practices, staff understanding of relevant policies, learning from deaths in custody, and organisational candour.
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 implement learning from investigations following deaths in custody
Wider context from the report “5. A failure to implement learning from the investigations that follow deaths in custody
Many of the staff giving evidence explained that they had not read the PPO report, nor were they aware of the issues identified by the PPO prior to giving evidence at the inquest. I have seen no evidence of the systems in place at HMP Lowdham Grange to seek to learn from deaths in custody at the earliest opportunity .
” 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 and potentially inaccurate Early Learning Review investigation methodology
Wider context from the report “6. Poor Quality Early Learning Review process, November 2021
While it is recognised that the ELR process is designed to capture information at a very early stage of the investigation, it is nevertheless an important tool in seeking to identify safety issues that should be addressed swiftly in order to prevent future deaths.
The central issue in this case was obvious from the outset, as recorded in various intelligence reports submitted by staff on the night of the death, namely, a number of members of staff suspected Kane to be under the influence of alcohol yet failed to take the necessary steps to seek to safeguard against harm.
On page 4 of the ELR it is concluded that “all procedures were followed” and there were no local or national recommendations for learning lessons. It is difficult to rationalise this conclusion against the evidence available even at the earliest stages of the investigation. The author was clearly aware that staff had considered Kane to be under the influence of alcohol (see page 1) and should have been aware that no Under the Influence Log existed. The author simply notes that “the policy has been reviewed”. There is no explanation as to why the policy wasn’t followed. Was the policy unclear in its requirements? Was there an absence of staff training on the policy? Of great concern to me is the fact that staff giving evidence at the inquest still seemed to fail to grasp the significance of intoxication as a risk factor for self harm.
My concerns extend beyond the quality of the report, but also to the accuracy of the same.
The report is written in such a way as to create the impression that the author interviewed key members of staff. Comments are attributed to staff in particular points in time, yet all prison staff witnesses denied ever having been interviewed as part of the ELR process . It is unclear exactly what methodology the author has used during the investigation . I am concerned that the quality of the investigation has led to missed opportunities to have identified these issues at the outset .
” 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 control the deliberate ignoring of prisoner cell bells
Wider context from the report “1. Ignoring Cell Bells
I heard evidence that staff were engaging in the deliberate ignoring of prisoner cell bells . I have seen no local policy which either prohibits such activity, or, if such activity is permitted, supports staff to make risk-based considerations about how and when to ignore cell bells .
I observe that deliberately ignoring cell bells appears to be a wholly dangerous practice as the cell bell is the only method of communication between prisoner and staff during periods of lock up, including night state. The practice appears to be all the more dangerous when one considers some staff suspected Kane to be in a state of heightened emotion and acting under the influence of alcohol.
” 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 governing the isolation of power to cells
Wider context from the report “2. Isolating power to cells
As above, I have seen no policy which supports the isolation of power to cells including who has the power to make such a decision, how long the power should be isolated for, and whether staff are required to consider any risk factors when determining whether to isolate power to the cell.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to follow the Under the Influence Policy
Wider context from the report “3. Failure to follow the local Under the Influence Policy
Three members of staff suspected Kane was under the influence of something in the hours before his death, yet none opened an under the influence log or sought any medical advice about how frequently to check on him, what signs of deterioration to look out for, and when to seek further assistance .
” 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 Poor quality Early Learning Review failing to identify safety issues and learning
Wider context from the report “6. Poor Quality Early Learning Review process, November 2021
While it is recognised that the ELR process is designed to capture information at a very early stage of the investigation, it is nevertheless an important tool in seeking to identify safety issues that should be addressed swiftly in order to prevent future deaths.
The central issue in this case was obvious from the outset, as recorded in various intelligence reports submitted by staff on the night of the death, namely, a number of members of staff suspected Kane to be under the influence of alcohol yet failed to take the necessary steps to seek to safeguard against harm.
On page 4 of the ELR it is concluded that “all procedures were followed” and there were no local or national recommendations for learning lessons . It is difficult to rationalise this conclusion against the evidence available even at the earliest stages of the investigation. The author was clearly aware that staff had considered Kane to be under the influence of alcohol (see page 1) and should have been aware that no Under the Influence Log existed. The author simply notes that “the policy has been reviewed”. There is no explanation as to why the policy wasn’t followed . Was the policy unclear in its requirements? Was there an absence of staff training on the policy? Of great concern to me is the fact that staff giving evidence at the inquest still seemed to fail to grasp the significance of intoxication as a risk factor for self harm.
My concerns extend beyond the quality of the report, but also to the accuracy of the same.
The report is written in such a way as to create the impression that the author interviewed key members of staff. Comments are attributed to staff in particular points in time, yet all prison staff witnesses denied ever having been interviewed as part of the ELR process. It is unclear exactly what methodology the author has used during the investigation. I am concerned that the quality of the investigation has led to missed opportunities to have identified these issues at the outset.
” 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 understanding and training on key dates or anniversaries as self-harm risk factors
Wider context from the report “4. Lack of understanding of Prison Service Instruction 64/2011, and possible discord between local policy and the PSI
A number of prison officers believed Kane’s birthday was incapable of amounting to a “key date or anniversary” for the purposes of PSI 64/2011 . It seems to me to common sense that a birthday, being the anniversary of one’s birth, could amount to a potential trigger date for heightened emotions when considering a prisoner’s risk of self harm and suicide. That is not to say it would be so for each and every prisoner, but perhaps something to be cognisant of when dealing with an emotional and intoxicated prisoner. I have seen no evidence that this is covered in Sodexo’s training for staff on the ACCT process , if indeed any series of training exists.
A number of prison officers gave evidence that an ACCT was not necessary because Kane had not said to anyone that he was going to harm himself (either fatally or otherwise). Serco’s Safer Prison Operating Policy (August 2022) is confusing on this point and seems to suggest at paragraph 3.4 that staff should only open an ACCT when a statement of self-harm has been verbalised. This is not consistent with the PSI. Sodexo have not offered for scrutiny any local policy, guidance or training material on the threshold for opening an ACCT, but even if such exists, it appears some staff continue to labour under the misapprehension that a prisoner must say they are thinking of harming themselves before an ACCT can be opened.
” 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 the ACCT threshold without a verbalised self-harm statement
Wider context from the report “4. Lack of understanding of Prison Service Instruction 64/2011, and possible discord between local policy and the PSI
A number of prison officers believed Kane’s birthday was incapable of amounting to a “key date or anniversary” for the purposes of PSI 64/2011. It seems to me to common sense that a birthday, being the anniversary of one’s birth, could amount to a potential trigger date for heightened emotions when considering a prisoner’s risk of self harm and suicide. That is not to say it would be so for each and every prisoner, but perhaps something to be cognisant of when dealing with an emotional and intoxicated prisoner. I have seen no evidence that this is covered in Sodexo’s training for staff on the ACCT process, if indeed any series of training exists.
A number of prison officers gave evidence that an ACCT was not necessary because Kane had not said to anyone that he was going to harm himself (either fatally or otherwise). Serco’s Safer Prison Operating Policy (August 2022) is confusing on this point and seems to suggest at paragraph 3.4 that staff should only open an ACCT when a statement of self-harm has been verbalised. This is not consistent with the PSI. Sodexo have not offered for scrutiny any local policy, guidance or training material on the threshold for opening an ACCT, but even if such exists, it appears some staff continue to labour under the misapprehension that a prisoner must say they are thinking of harming themselves before an ACCT can be opened .
” 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 agreed factual admissions of shortcomings during death in custody inquests
Wider context from the report “7. A Lack of Candour – both organisationally and individually
I would be very interested to understand how the duty of candour applies to the prison service and those individuals within the employ of the service (whether employed directly or through a private provider, as in this case).
There is a statutory duty of candour applicable to healthcare organisations and professionals, as well as a more recent agreement by the College of Policing for members to adhere to a Code of Candour.
In practise, candour creates a culture of being open and honest with all stakeholders by accepting when things go wrong, taking remedial steps as soon as practicable, and thus reducing the risk of events repeating themselves. In the context of a death, candour from the outset is essential in order to support the bereaved family.
The position adopted by Serco in this inquest, as it has in other inquests, could be said to represent the very opposite of candour. Having heard evidence supplied on oath by their own staff members that there were multiple failures to open an under the influence log (evidence which was not contested) the organisation nevertheless required the Jury to return a finding on this issue, and each and every issue, instead of a factual finding being presented to the jury as agreed by all Interested Persons .
The inquest is not an adversarial process, there is no burden of proof. The Interested Persons are under a duty to assist the investigative process in an open and honest manner. By identifying those issues that genuinely require determination by the jury, and those on which there is agreement. Sadly, in my extensive experience of conducting Article 2 inquests locally, this is not an isolated example of the uncomfortable position adopted by the prison service in failing to put forward sensible and reasonable factual admissions of shortcomings.
I am concerned by the apparent absence of a culture of candour supporting those staff who work within the prison service. Many of the staff members giving evidence explained that the inquest was the first time it had been suggested to them that they had not adhered to policy. In the intervening period of over two years between Kane’s death and the inquest, no-one at the prison had asked key staff to reflect on the care they provided to Kane that night and consider areas of learning. Again, this is not a position unique to this inquest, and is of great concern in the context of a rising number of self-inflicted prisoner deaths at HMP Lowdham Grange since Kane’s tragic death in 2021.
I would be grateful if your response could address what steps have been, or are being taken, to ensure that candour is applied throughout the death in custody process.
” 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 culture of candour and staff reflection after deaths in custody
Wider context from the report “7. A Lack of Candour – both organisationally and individually
I would be very interested to understand how the duty of candour applies to the prison service and those individuals within the employ of the service (whether employed directly or through a private provider, as in this case).
There is a statutory duty of candour applicable to healthcare organisations and professionals, as well as a more recent agreement by the College of Policing for members to adhere to a Code of Candour.
In practise, candour creates a culture of being open and honest with all stakeholders by accepting when things go wrong, taking remedial steps as soon as practicable, and thus reducing the risk of events repeating themselves. In the context of a death, candour from the outset is essential in order to support the bereaved family.
The position adopted by Serco in this inquest, as it has in other inquests, could be said to represent the very opposite of candour. Having heard evidence supplied on oath by their own staff members that there were multiple failures to open an under the influence log (evidence which was not contested) the organisation nevertheless required the Jury to return a finding on this issue, and each and every issue, instead of a factual finding being presented to the jury as agreed by all Interested Persons.
The inquest is not an adversarial process, there is no burden of proof. The Interested Persons are under a duty to assist the investigative process in an open and honest manner. By identifying those issues that genuinely require determination by the jury, and those on which there is agreement. Sadly, in my extensive experience of conducting Article 2 inquests locally, this is not an isolated example of the uncomfortable position adopted by the prison service in failing to put forward sensible and reasonable factual admissions of shortcomings.
I am concerned by the apparent absence of a culture of candour supporting those staff who work within the prison service . Many of the staff members giving evidence explained that the inquest was the first time it had been suggested to them that they had not adhered to policy. In the intervening period of over two years between Kane’s death and the inquest, no-one at the prison had asked key staff to reflect on the care they provided to Kane that night and consider areas of learning . Again, this is not a position unique to this inquest, and is of great concern in the context of a rising number of self-inflicted prisoner deaths at HMP Lowdham Grange since Kane’s tragic death in 2021.
I would be grateful if your response could address what steps have been, or are being taken, to ensure that candour is applied throughout the death in custody process.
” 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 and use national guidance and a standard template to improve the consistency and quality of Early Learning Reviews.
Verbatim wording from the response “In 2021 the National Safety Team issued guidance and a standard template to assist those conducting the reviews and to bring greater consistency to the reports, which improved the overall quality. Being implemented during the COVID-19 pandemic meant our ability to deliver face-to-face training was limited and as such we have continued to work to improve the quality of ELRs, including holding a workshop with GSLs in July 2022 at which the National Safety Team shared the results of a review of a sample of reports and provided feedback designed to improve practice in the conduct of the reviews and the writing of the reports.” 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 Remind staff through senior leaders and the legal team to provide fully transparent statements and live evidence during death-in-custody investigations.
Verbatim wording from the response “I take our responsibility to assist the Coroner to properly explore the circumstances of any death extremely seriously, and our staff are reminded by senior leaders and our legal team of the need to be completely transparent in their statements and live evidence, and we will always seek to made admissions where appropriate.” 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 Develop a new policy framework that mandates Early Learning Reviews and assigns Prison Group Directors responsibility for checking report quality before sign-off.
Verbatim wording from the response “We continue to monitor the quality of ELRs and to share feedback on them with GSLs. We are currently working on a new policy framework on the follow-up to deaths in custody (replacing PSI 64/2011) and intend to use that to mandate the early learning review process, and to make clear that it is the responsibility of the Prison Group Director to satisfy themselves of the quality of the ELR before signing the report off. Alongside the new policy framework, we will issue a revised standard template and a refreshed guidance document.” 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 Deliver workshops and feedback to Group Safety Leads to improve their Early Learning Review skills, practice and report writing.
Verbatim wording from the response “In 2021 the National Safety Team issued guidance and a standard template to assist those conducting the reviews and to bring greater consistency to the reports, which improved the overall quality. Being implemented during the COVID-19 pandemic meant our ability to deliver face-to-face training was limited and as such we have continued to work to improve the quality of ELRs, including holding a workshop with GSLs in July 2022 at which the National Safety Team shared the results of a review of a sample of reports and provided feedback designed to improve practice in the conduct of the reviews and the writing of the reports.” 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 Monitor Early Learning Review quality and share feedback with Group Safety Leads.
Verbatim wording from the response “We continue to monitor the quality of ELRs and to share feedback on them with GSLs. We are currently working on a new policy framework on the follow-up to deaths in custody (replacing PSI 64/2011) and intend to use that to mandate the early learning review process, and to make clear that it is the responsibility of the Prison Group Director to satisfy themselves of the quality of the ELR before signing the report off. Alongside the new policy framework, we will issue a revised standard template and a refreshed guidance document.” 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 Issue a revised Early Learning Review standard template and refreshed guidance alongside the new policy framework.
Verbatim wording from the response “We continue to monitor the quality of ELRs and to share feedback on them with GSLs. We are currently working on a new policy framework on the follow-up to deaths in custody (replacing PSI 64/2011) and intend to use that to mandate the early learning review process, and to make clear that it is the responsibility of the Prison Group Director to satisfy themselves of the quality of the ELR before signing the report off. Alongside the new policy framework, we will issue a revised standard template and a refreshed guidance document.” 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 Seek admissions where appropriate when assisting coroners to establish the circumstances of deaths in custody.
Verbatim wording from the response “I take our responsibility to assist the Coroner to properly explore the circumstances of any death extremely seriously, and our staff are reminded by senior leaders and our legal team of the need to be completely transparent in their statements and live evidence, and we will always seek to made admissions where appropriate.” Source location Response from HMPPS
Open published response
16 Jan 2024 Trevor Alan MONERVILLE · Prevention of Future Deaths report East Sussex
View report summary
Concerns raised 6 Lack of a mechanism to report medication non-compliance to Security View source Lack of prison staff training in managing long-term health conditions on the wings View source Failure of the CSRA policy to protect prisoners with relevant medical conditions View source Lack of individualized seizure care planning and monitoring View source Inadequate communication about prisoners’ health conditions View source Deficit in national policy for managing and supporting prisoners with epilepsy and seizures View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Trevor Alan MONERVILLE · 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
Trevor Alan Monerville, who had been detained at HMP Lewes, was found unresponsive in his cell on 18 April 2021 and died after suffering from epilepsy and non-epileptic attack disorder. The principal concerns were inadequate monitoring and management of his epilepsy after the ACCT closed, poor communication and information-sharing between healthcare, prison staff and family, and insufficient staff training in managing epilepsy and seizures.
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 a mechanism to report medication non-compliance to Security
Wider context from the report “b. Communication between healthcare and prison staff especially when Trevor was returned to the wing, between the prison staff and family, briefing by prison managers to officers on the wing about Trevor’s condition were all inadequate.
Evidence was heard about the lack of integration of various IT systems which contributed to poor communication. In spite of the evidence from PPG regarding the sensitivity of medical records which should not be disclosed to the prison staff, I remain concerned that there was no effective monitoring and management of Trevor on the wing once the ACCT was closed. There was no mechanism in place for prison and healthcare staff to report their concerns about Trevor’s non compliance with taking his medication to Security , thus preventing the cell from being searched for retained medication.
” 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 training in managing long-term health conditions on the wings
Wider context from the report “c. There was a lack of training of prison staff in dealing with long term health conditions such as epilepsy on the wings. I understand there is a deficit in national policy within the prison service to manage and support prisoners with epilepsy and seizures.
” 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 the CSRA policy to protect prisoners with relevant medical conditions
Wider context from the report “a. Consideration should be given to the review of the treatment, monitoring and management of patients with a history of epilepsy or seizures by both the prison staff and healthcare staff. In particular, there was no seizure care plan, no seizure diary and once the ACCT had closed on 10th March 2021, there was no formal mechanism of monitoring Trevor’s condition. Further, the ACCT is not a suitable mechanism for such monitoring. The CSRA policy is designed to protect other prisoners, but not those who suffer from medical conditions as Trevor suffered. PPG in their evidence to be considered relating to PFD matters state that a care plan dashboard is now in place at HMP Lewes but this does not appear to be individualized or tailored to the prisoner’s clinical requirements.
” 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 individualized seizure care planning and monitoring
Wider context from the report “a. Consideration should be given to the review of the treatment, monitoring and management of patients with a history of epilepsy or seizures by both the prison staff and healthcare staff. In particular, there was no seizure care plan, no seizure diary and once the ACCT had closed on 10th March 2021, there was no formal mechanism of monitoring Trevor’s condition . Further, the ACCT is not a suitable mechanism for such monitoring. The CSRA policy is designed to protect other prisoners, but not those who suffer from medical conditions as Trevor suffered. PPG in their evidence to be considered relating to PFD matters state that a care plan dashboard is now in place at HMP Lewes but this does not appear to be individualized or tailored to the prisoner’s clinical requirements .
” 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 communication about prisoners’ health conditions
Wider context from the report “b. Communication between healthcare and prison staff especially when Trevor was returned to the wing , between the prison staff and family , briefing by prison managers to officers on the wing about Trevor’s condition were all inadequate.
Evidence was heard about the lack of integration of various IT systems which contributed to poor communication. In spite of the evidence from PPG regarding the sensitivity of medical records which should not be disclosed to the prison staff, I remain concerned that there was no effective monitoring and management of Trevor on the wing once the ACCT was closed. There was no mechanism in place for prison and healthcare staff to report their concerns about Trevor’s non compliance with taking his medication to Security, thus preventing the cell from being searched for retained medication.
” 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 Deficit in national policy for managing and supporting prisoners with epilepsy and seizures
Wider context from the report “c. There was a lack of training of prison staff in dealing with long term health conditions such as epilepsy on the wings. I understand there is a deficit in national policy within the prison service to manage and support prisoners with epilepsy and seizures.
” 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 Deliver First Aid at Work and Emergency First Aid training to identified prison staff, including responses to seizures.
Verbatim wording from the response “HMPPS undertake First Aid needs assessments to ensure that sufficient emergency aid response is available on each site. First Aid at Work and Emergency First Aid training courses are delivered to identified prison staff, which includes emergency response to both minor and major seizures.” 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 NHS England to clarify routine health-information sharing and processes for risk or safeguarding concerns.
Verbatim wording from the response “HMPPS recognises that, information sharing is vital to effective health management of people in prison and is working closely with NHSE to increase staff confidence and support effective information sharing by offering clarity about the general and routine sharing of health information and where risk/safeguarding concerns have been raised.” 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 Healthcare provider PPG is responsible for seizure care plans, diaries and long-term health management; prison staff facilitate its instructions.
Verbatim wording from the response “As was heard at the inquest, the creation of a seizure care plan and seizure diary, a clinical matter, falls within the responsibility of the healthcare provider at HMP Lewes, Practice Plus Group (PPG). It is within PPG’s remit to decide which prisoners are fit to be managed on a standard wing and, where a health condition such as epilepsy is identified, whether the severity of this means they should be located on the inpatient wing. HMPPS will facilitate a move to the inpatient unit where this is required.” 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 information-sharing protocols and weekly meetings are considered appropriate for communication and management of complex safety concerns.
Verbatim wording from the response “There are Information Sharing protocols in place, as directed by national policy, which underpin the exchange of information between healthcare and prison staff. There are several regular meetings involving healthcare and prison staff where individual issues are raised and addressed, including the Safety Intervention Meeting and Multi-Disciplinary Complex Case Clinic, both of which are held weekly.” 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 PPG decides whether prisoners with epilepsy require standard or inpatient placement; HMPPS facilitates any required move.
Verbatim wording from the response “As was heard at the inquest, the creation of a seizure care plan and seizure diary, a clinical matter, falls within the responsibility of the healthcare provider at HMP Lewes, Practice Plus Group (PPG). It is within PPG’s remit to decide which prisoners are fit to be managed on a standard wing and, where a health condition such as epilepsy is identified, whether the severity of this means they should be located on the inpatient wing. HMPPS will facilitate a move to the inpatient unit where this is required.” Source location Response from HM Prison and Probation Service
Open published response
4 Jan 2024 Stephen COSTER · Prevention of Future Deaths report East Sussex
View report summary
Concerns raised 12 Failure by healthcare staff to escalate sick prisoners’ cases View source Failure by healthcare staff to carry out adequate observations View source Failure by healthcare staff to properly assess a sick prisoner’s condition View source Inadequate understanding among prison staff of the local policy for emergency hospital transfer with retrospective risk assessment View source Inadequate leadership by prison staff View source Absence of a protocol or policy for healthcare-prison communication when monitoring sick prisoners on the wing at night View source Poor and inadequate record keeping by prison staff View source Breakdown in communication among junior prison staff View source Breakdown in healthcare-prison communication about emergency hospital transfer View source Failure by healthcare staff to provide prison staff with an adequate care plan View source Inadequate information in healthcare paperwork about a sick prisoner’s condition View source Inadequate understanding among prison staff about when to call Code Blue View source See 9 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Stephen COSTER · 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
Stephen Coster died from meningoencephalitis owing to Streptococcus pneumoniae after becoming seriously unwell while detained at HMP Lewes. The inquest found delays in providing treatment and transferring him to hospital, with concerns including inadequate observations and assessment, poor record keeping, failures to escalate, and breakdowns in communication and leadership between prison and healthcare staff.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure by healthcare staff to escalate sick prisoners’ cases
Wider context from the report “b. A failure by healthcare staff to carry out adequate observations and to properly assess Stephen Coster’s condition as well as a failure to escalate his case .
” 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 by healthcare staff to carry out adequate observations
Wider context from the report “b. A failure by healthcare staff to carry out adequate observations and to properly assess Stephen Coster’s condition as well as a failure to escalate his case.
” 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 by healthcare staff to properly assess a sick prisoner’s condition
Wider context from the report “b. A failure by healthcare staff to carry out adequate observations and to properly assess Stephen Coster’s condition as well as a failure to escalate his case.
” 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 understanding among prison staff of the local policy for emergency hospital transfer with retrospective risk assessment
Wider context from the report “f. An inadequate understanding amongst prison staff about the local policy to transfer emergency cases to hospital with a retrospective risk assessment .
” 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 leadership by prison staff
Wider context from the report “g. Inadequate leadership by prison staff leading to a breakdown in communication amongst junior prison staff which caused the delay in transferring Stephen from the prison to hospital.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Absence of a protocol or policy for healthcare-prison communication when monitoring sick prisoners on the wing at night
Wider context from the report “c. Healthcare staff failed to provide the prison staff with an adequate care plan so that Stephen Coster could be monitored effectively. Evidence was heard that there was no protocol or policy in place regarding communication between Healthcare staff and Prison staff for the monitoring of sick prisoners on the wing at night .
” 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 Poor and inadequate record keeping by prison staff
Wider context from the report “a. Evidence was heard relating to poor and inadequate record keeping by prison 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 Breakdown in communication among junior prison staff
Wider context from the report “g. Inadequate leadership by prison staff leading to a breakdown in communication amongst junior prison staff which caused the delay in transferring Stephen from the prison to hospital.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Breakdown in healthcare-prison communication about emergency hospital transfer
Wider context from the report “e. There was a breakdown in communication between healthcare staff and prison staff regarding transferring a sick prisoner to hospital as an emergency . Further, there was inadequate information included on the paperwork prepared by healthcare staff about Stephen Coster’s condition resulting in delay in arranging for his urgent escort and transfer to hospital.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure by healthcare staff to provide prison staff with an adequate care plan
Wider context from the report “c. Healthcare staff failed to provide the prison staff with an adequate care plan so that Stephen Coster could be monitored effectively. Evidence was heard that there was no protocol or policy in place regarding communication between Healthcare staff and Prison staff for the monitoring of sick prisoners on the wing at night.
” 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 information in healthcare paperwork about a sick prisoner’s condition
Wider context from the report “e. There was a breakdown in communication between healthcare staff and prison staff regarding transferring a sick prisoner to hospital as an emergency. Further, there was inadequate information included on the paperwork prepared by healthcare staff about Stephen Coster’s condition resulting in delay in arranging for his urgent escort and transfer to hospital.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Inadequate understanding among prison staff about when to call Code Blue
Wider context from the report “d. There was inadequate understanding amongst prison staff about when to call Code Blue .
” 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 Have the Assistant Orderly Officer attend every Code Blue or Code Red to oversee incident management and maintain standards.
Verbatim wording from the response “Following a review into incident management the Assistant Orderly Officer now attends each Code Blue/Red to personally oversee, provide direction, and ensure standards are kept, ensuring effective leadership during the management of the incident.” 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 Share the escort-review findings with healthcare staff to improve communication and clarify urgency during hospital escorts.
Verbatim wording from the response “Following the death of Mr Coster and the PPO’s recommendations, the Deputy Governor and Head of Safety conducted a review into the circumstances of the prison escort to hospital. Their findings identified a need for improved communication with and greater clarity from healthcare staff to ensure that urgency of the matter is made clear to prison staff. This has been shared with healthcare.” 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 an agreed system clarifying prison welfare checks, healthcare clinical observations, required check levels and clinically appropriate inpatient transfers.
Verbatim wording from the response “The prison has also conducted a further review, together with healthcare, to consider how best to manage the care and monitoring of unwell prisoners. An agreed system is now in place which clarifies that prison staff are responsible for welfare checks and medical staff are responsible for clinical observations. Healthcare staff inform prison staff of the need for checks on a particular prisoner and what level of check is required. Where healthcare feel it is clinically appropriate, a move to the inpatient unit at the prison will be facilitated so that healthcare staff are present to undertake all observations.” 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 Actively review the emergency-escort policy.
Verbatim wording from the response “Custodial Managers have the authority to dispatch an emergency escort without the relevant risk assessment where the life of a prisoner is in danger. The Local Operating Procedure for Hospital Escorts and Bedwatches refers to escorts being dispatched without the relevant risk assessment where there is an ‘emergency.’ The policy on emergency escorts as a whole is being actively reviewed.” 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 Remind staff to record all relevant information, including smaller prisoner interactions.
Verbatim wording from the response “Following the Fact-Finding report on 16 May 2022 HMP Lewes undertook a review of record-keeping practices which identified a generally very good approach by staff. Issues identified, such as the need for staff to record smaller interactions, have been addressed, with staff being reminded of the need to record all relevant information.” 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 Continue briefing, training and distributing reminders to staff on using Code Red and Code Blue and immediately calling emergency services.
Verbatim wording from the response “The prison continues to brief staff regularly regarding the appropriate use of Code Red and Code Blue, and the importance of using them to ensure the emergency services are called immediately. Shortly after Mr Coster's death, a Notice to Staff was sent out to raise awareness and remind staff of their responsibilities. This was followed up by reminders in the Safety Newsletter later in the year and the Safety Nudge the following year. A number of training events have also taken place, delivered by the Safety Team, on the emergency” Source location Response from HM Prison and Probation Service
Open published response
21 Dec 2023 Wyndham Richard Thomas · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 4 Unavailability of in-cell ligature point maps to staff View source Lack of in-cell ligature point risk assessments View source Unavailability of designated Safer Cells View source Lack of a mandatory requirement for prisons to provide access to Safer 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.
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AI-generated summary
Wyndham Richard Thomas · 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
Wyndham Richard Thomas was a serving prisoner who was found unconscious in his cell after ligating on 4 November 2018 and died in hospital on 6 November 2018. The substantive concerns were the absence of in-cell ligature-point risk assessments and maps, and the lack of designated safer cells at HMP Nottingham, which reduced opportunities to mitigate the risk of self-harm and death by ligature asphyxiation.
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 in-cell ligature point maps to staff
Wider context from the report “1. There is a lack of local and national system of in-cell ligature point risk assessments, and no ligature point maps available to staff .
The Prison Staff caring for Wyndham were not aware of the location of known ligature points within the cell . This meant that suspicion was not drawn when Wyndham was seen positioned in an area which had access to a ligature point.
” 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 in-cell ligature point risk assessments
Wider context from the report “1. There is a lack of local and national system of in-cell ligature point risk assessments , and no ligature point maps available to staff.
The Prison Staff caring for Wyndham were not aware of the location of known ligature points within the cell. This meant that suspicion was not drawn when Wyndham was seen positioned in an area which had access to a ligature point.
” 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 designated Safer Cells
Wider context from the report “2. There is no mandatory requirement for a HMP Prison to have access to a Safer Cell (one with reduced ligature points) available to staff.
HMP Nottingham does not have designated Safer Cells , including on the Care and Support Unit , where prisoners posing a high risk of harm by ligation may be sent for their own safety.
” 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 mandatory requirement for prisons to provide access to Safer Cells
Wider context from the report “2. There is no mandatory requirement for a HMP Prison to have access to a Safer Cell (one with reduced ligature points) available to staff .
HMP Nottingham does not have designated Safer Cells, including on the Care and Support Unit, where prisoners posing a high risk of harm by ligation may be sent for their own safety.
” 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 Convert selected cells in older prisons to ligature-resistant standards, prioritising prisons with recent self-inflicted deaths.
Verbatim wording from the response “At a national level, HMPPS has undertaken a review of ligature-resistant cells, which have been designed to eliminate ligature points as far as possible. The review included their build standards and how they are used to support prisoners in crisis. Our aim is to ensure that cells that are fitted with ligature-resistant features are available as an option for staff managing prisoners in crisis, and that they retain those features in full working order and do not deviate from the standard over time. All new prisons and major additions, such as new wings, are usually built without ligature points in cells. For older prisons, HMPPS has begun to convert a number of cells to the same standard. Due to the high costs associated with this renovation work, priority is being given to” 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 High renovation costs prevent mandating ligature-resistant cells in every prison at this stage.
Verbatim wording from the response “At a national level, HMPPS has undertaken a review of ligature-resistant cells, which have been designed to eliminate ligature points as far as possible. The review included their build standards and how they are used to support prisoners in crisis. Our aim is to ensure that cells that are fitted with ligature-resistant features are available as an option for staff managing prisoners in crisis, and that they retain those features in full working order and do not deviate from the standard over time. All new prisons and major additions, such as new wings, are usually built without ligature points in cells. For older prisons, HMPPS has begun to convert a number of cells to the same standard. Due to the high costs associated with this renovation work, priority is being given to” 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 Existing observation escalation and gated-cell relocation are relied on to manage high-risk prisoners.
Verbatim wording from the response “With regards to your concerns pertaining to in-cell ligature point risk assessments and the availability of ligature point maps, we expect staff to be aware of the potential for a prisoner to be equally at risk of ligaturing at any position in the cell, as well as to the possibility that a ligature point may not be used in all circumstances that require immediate action to preserve life. Prisoners assessed as high risk of suicide should either have their observation level increased or they should be relocated into a gated cell, if doing so would not be detrimental to the prisoner’s welfare.” Source location Response from HM Prison 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