Concerns raised 5 Failure to carry out scheduled ACCT observations View source Failure to maintain accurate and complete ACCT observation records View source Lack of a collective inter-agency response to learning lessons View source Failure to ensure transfer for psychiatric treatment where required View source Failure to ensure correct levels of observation up to constant watch 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
Martin Samuel WILLIS · 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
Martin Samuel Willis was a serving prisoner at HMP Stoke Heath when he was found hanging in his cell on 15 September 2022. He was on the suicide and self-harm prevention scheme, but concerns included failures in observation recording and supervision, uncertainty about the appropriate observation level and possible transfer for mental health treatment, and the need for a collective review of the care provided.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out scheduled ACCT observations
Wider context from the report “1. The ACCT procedure was not properly implemented, complied with or supervised . A scheduled observation at 8 am did not take place and a false entry was entered at 7:30 am and later deleted. The last correct entry was at 7 am with earlier omissions.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 accurate and complete ACCT observation records
Wider context from the report “1. The ACCT procedure was not properly implemented, complied with or supervised . A scheduled observation at 8 am did not take place and a false entry was entered at 7:30 am and later deleted . The last correct entry was at 7 am with earlier omissions .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 collective inter-agency response to learning lessons
Wider context from the report “4. Whilst the prison service and the mental health providers have reviewed the circumstances of Mr Willis’s death, I am concerned that there should be a collective and not individual response to ensure that all lessons can be learned . I therefore recommend that there be an inter-agency review between the prison service and mental health services as to the mental health care provided to the late Mr Willis including the evidence at the inquest and the jury’s findings. In so doing, I do not purport to suggest what the outcome of the review should be.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 transfer for psychiatric treatment where required
Wider context from the report “3. Overriding issues remain as to whether or not the late Mr Willis was on the correct levels of observation up to constant watch and whether he should have been transferred to an psychiatric grounds for treatment at another prison establishment with a hospital wing .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 correct levels of observation up to constant watch
Wider context from the report “3. Overriding issues remain as to whether or not the late Mr Willis was on the correct levels of observation up to constant watch and whether he should have been transferred to an psychiatric grounds for treatment at another prison establishment with a hospital wing.
” 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 Present an operational briefing to all staff on assigned ACCT-check responsibilities.
Verbatim wording from the response “ACTION TO BE TAKEN:
I will be presenting an Operational Briefing on 21st December to all staff, taking into consideration the Governors Order GO 01/2023 which reads as follows:” Source location 2024-0171 - 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 Case Co-Ordinators to verify document completion and specify clear, precise observation intervals before reviews.
Verbatim wording from the response “• Prior to all reviews the Case Co-Ordinator will ensure that all relevant documents have been completed and that all observations are clear and precise for example 5x observations per day every 2 hours or 3 x observations during the day every 3 hours.” Source location 2024-0171 - 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 Supervising Officers to complete daily checks and challenge staff where necessary.
Verbatim wording from the response “• Supervising Officers will ensure the daily checks are completed and staff challenged accordingly.” Source location 2024-0171 - 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 Supervising Officers to check the preceding 24 hours of ACCT records daily and challenge discrepancies.
Verbatim wording from the response “• The Supervising Officer will check daily to ensure that the previous 24 hours have been recorded accurately and any discrepancies challenged accordingly.” Source location 2024-0171 - 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 Consider constant supervision when ligature material has been removed.
Verbatim wording from the response “• Removal of any ligature material suggests that the prisoner is an immediate threat to themselves and therefore constant supervision will be considered.” Source location 2024-0171 - 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 Organise and hold a Good Practice Meeting for case-review partners to share and discuss complex reviews and good practice.
Verbatim wording from the response “• A Good Practise Meeting will be organised and held by the Safer Custody Team inclusive of all Case Co-Ordinators, Mental Health Teams and external providers to share and discuss complex case reviews and good practises.” Source location 2024-0171 - 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 Incorporate the Governors Order on ACCT checks into ACCT V6 training delivered to staff.
Verbatim wording from the response “This Governors Order will also be incorporated into all ACCT V6 training which is delivered to all staff by our Regional Safety Team and inhouse trainers.” Source location 2024-0171 - 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 Meet Partner Agencies to communicate their responsibilities in multi-agency reviews.
Verbatim wording from the response “ACTION TO BE TAKEN:
I will be meeting with all Partner Agencies and relaying their responsibilities. Awareness Training for all Partner Agencies staff has been organised.” Source location 2024-0171 - 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 Case Co-Ordinators to record reasons when a discussed constant watch is deemed inappropriate.
Verbatim wording from the response “• Case Co-ordinators have been reminded that if a constant watch is discussed and deemed not appropriate then this should be recorded with an acceptable reason.” Source location 2024-0171 - 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 Share quality-assurance findings with relevant managers and retain confirmation that identified errors were rectified.
Verbatim wording from the response “• Safer Custody and Senior Leadership Team (SLT) will ensure all QA is shared with relevant managers, and a confirmation email that the errors have been rectified will be saved as evidence.” Source location 2024-0171 - 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 Senior Officers and Custodial Managers are not responsible for allocating ACCT checks; responsibility is assigned to designated operational staff.
Verbatim wording from the response “The purpose of this Governors Orders is to make you aware that it is the responsibility of the Cleaning Officer to ensure that ACCT observations and conversations are conducted and recorded in the ACCT document between the hours of 0745 - 1715.” Source location 2024-0171 - Response from HMPPS
Open published response
5 Dec 2023 Samuel Lewis Jones · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 4 Lack of flagging of and access to key dates affecting prisoners’ safety View source Lack of national guidance for managing in-possession medication View source Failure of NOMIS information accessibility to support risk assessments View source Lack of national guidance for managing safety risks associated with key dates 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
Samuel Lewis Jones · 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
Samuel Lewis Jones died on 30 April 2021 after suspending himself by a ligature in his cell at HMP Portland. The concerns identified included the lack of systems and national guidance for recording and flagging significant dates, difficulties accessing key information in prison records, and insufficient national guidance on managing medication held in prisoners’ possession.
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 flagging of and access to key dates affecting prisoners’ safety
Wider context from the report “i. The lack of flagging of, and access to, key dates which may have an impact on prisoners’ 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 national guidance for managing in-possession medication
Wider context from the report “iv. The lack of national guidance around the operation of in possession medication in prisons either by HMPPS or NHS England to ensure prisoners do not stockpile or retain medication when they have stopped using it .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 NOMIS information accessibility to support risk assessments
Wider context from the report “iii. The accessibility of information recorded on NOMIS and the potential to miss key information which could impact on risk assessments .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidance for managing safety risks associated with key dates
Wider context from the report “ii. The lack of national Prison Service or NHS guidance on how to manage key dates where risks to the safety of the prisoner may be increased , such as a bereavement or traumatic incident or any other key dates.
” 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 supporting staff guidance on providing suitable, coordinated care during key-date trigger periods.
Verbatim wording from the response “importance of recording information about such dates. We know that many prisons maintain local databases for this purpose. The importance of awareness that key dates may be triggers will also be made clear in the new Safety Policy Framework that we will shortly be issuing, which will be supported with guidance for staff about how to provide suitable, co-ordinated care during such trigger periods. In the meantime, we will issue a Senior Leaders Bulletin on the importance of recognising key dates and encouraging the use of local databases.” 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 Require medication removal during cell clearances through the amended Prisoners’ Property Policy Framework.
Verbatim wording from the response “In these circumstances prison staff are permitted to remove medication as an unauthorised item in accordance with the Searching Policy Framework, and the Prisoners’ Property Policy Framework has recently been amended to require the removal of medication during cell clearances.” Source location Response from HM Prison and Probation Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop Digital Prison Services as the replacement case management system, including core functionality needed to cease using NOMIS.
Verbatim wording from the response “Turning first to your concerns about key dates, as you know, NOMIS allows information to be shared throughout the system both within an establishment and nationally. We recognise that NOMIS, is no longer fit for purpose, and are currently developing a new case management system, Digital Prison Services (DPS). Whilst neither NOMIS nor DPS is currently able to record key dates, this is something that we will revisit as we continue to develop DPS. Our main focus for now, is to build the core functionality that is needed in DPS in order to enable us to cease the use of NOMIS.” Source location Response from HM Prison and Probation Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue a new Safety Policy Framework clarifying the importance of recognising key dates as potential triggers.
Verbatim wording from the response “importance of recording information about such dates. We know that many prisons maintain local databases for this purpose. The importance of awareness that key dates may be triggers will also be made clear in the new Safety Policy Framework that we will shortly be issuing, which will be supported with guidance for staff about how to provide suitable, co-ordinated care during such trigger periods. In the meantime, we will issue a Senior Leaders Bulletin on the importance of recognising key dates and encouraging the use of local databases.” 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 Revisit recording key dates in Digital Prison Services as its development continues.
Verbatim wording from the response “Turning first to your concerns about key dates, as you know, NOMIS allows information to be shared throughout the system both within an establishment and nationally. We recognise that NOMIS, is no longer fit for purpose, and are currently developing a new case management system, Digital Prison Services (DPS). Whilst neither NOMIS nor DPS is currently able to record key dates, this is something that we will revisit as we continue to develop DPS. Our main focus for now, is to build the core functionality that is needed in DPS in order to enable us to cease the use of NOMIS.” Source location Response from HM Prison and Probation Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue a Senior Leaders Bulletin on recognising key dates and encouraging use of local databases.
Verbatim wording from the response “importance of recording information about such dates. We know that many prisons maintain local databases for this purpose. The importance of awareness that key dates may be triggers will also be made clear in the new Safety Policy Framework that we will shortly be issuing, which will be supported with guidance for staff about how to provide suitable, co-ordinated care during such trigger periods. In the meantime, we will issue a Senior Leaders Bulletin on the importance of recognising key dates and encouraging the use of local databases.” 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 Consider adding keyword searching to Digital Prison Services.
Verbatim wording from the response “With regard to your third concern I have acknowledged above that NOMIS is not fit for purpose and explained that we are working on the development of DPS as a replacement. NOMIS does, however, provide the capacity for staff to search notes in various ways, including by type, subtype and date. The ability to search for key words is currently under consideration in the development of DPS, and we anticipate that this function will be available by 2025.” 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 NOMIS and DPS currently lack key-date recording and keyword-search functions while DPS core development is prioritised; these enhancements are planned or under consideration.
Verbatim wording from the response “Turning first to your concerns about key dates, as you know, NOMIS allows information to be shared throughout the system both within an establishment and nationally. We recognise that NOMIS, is no longer fit for purpose, and are currently developing a new case management system, Digital Prison Services (DPS). Whilst neither NOMIS nor DPS is currently able to record key dates, this is something that we will revisit as we continue to develop DPS. Our main focus for now, is to build the core functionality that is needed in DPS in order to enable us to cease the use of NOMIS.” 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 providers primarily decide which medication prisoners may hold in possession, although prison staff retain supporting responsibilities.
Verbatim wording from the response “With regard to your final concern, decisions about which medication can be issued to be held in possession by prisoners are primarily a matter for healthcare providers, but prison staff have a role to play, and this area in which collaborative working and appropriate information sharing are crucial. There are a number of prison policies that cover the stockpiling of medication, or its retention after an individual has ceased a course of treatment. Depending on the circumstances, healthcare staff may consider further treatment or intervention or it could constitute possession of an unauthorised item, which would be an offence against prison discipline as set out in the Adjudications Policy Framework.” Source location Response from HM Prison and Probation Service
Open published response
3 Oct 2023 Manoel Messias Santos · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 10 Failure to provide timely notification of immigration detention before release View source Delays and failures by the SSHD in progressing FNO cases and obtaining required information View source Delays by probation in allocating community offender managers and providing up-to-date OASYS reports View source Absence of a prison offender manager specialist model for FNO immigration liaison View source Failure to facilitate and signpost access to immigration legal advice View source Failure of communication between immigration and sentence-planning agencies View source Persistent misunderstanding of the policy governing OSG officers opening cell doors at night View source Insufficient communication of entitlement to free immigration legal advice View source Lack of clear systems for obtaining medical information View source Failure to disseminate and action important learning points View source See 7 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Manoel Messias Santos · 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
Manoel Messias Santos, a Brazilian national detained in prison and facing immigration detention and possible deportation, was found hanging in his cell in the early hours of 2 November 2020 and was declared dead at 3.30am. The jury found that his understanding of his immigration position made a material contribution to his death and identified failures in notifying him about the IS91 notice and communicating his immigration position. The report also raised concerns about delays in notification and case handling, access to legal advice, communication between agencies, dissemination of learning, and staff understanding of the policy on opening cell doors at night.
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 notification of immigration detention before release
Wider context from the report “2. The timing of the notification to Mr Santos by the SSHD that he was not to be released at the end of his custodial sentence but was to be held on immigration detention pending a decision on deportation. The SSHD target for notification is 30 days prior to release. In this case it was 8 days late. I heard PFD evidence that this 30-day target is not met in 40% of cases and that 83% of cases are notified within 7 days of the end of the sentence . I am concerned at the potential uncertainty and distress caused to Foreign National Offenders (“FNOs”) by notification at this stage.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 and failures by the SSHD in progressing FNO cases and obtaining required information
Wider context from the report “8. I am concerned at the potential impact of delays/failure to obtain information in other cases. In Mr Santos’ case there were delays by probation in allocating a community offender manager and providing an up-to-date OASYS report. There were also delays by the SSHD progressing Mr Santos’ case , including issue of the Stage 2 letter , failure to obtain medical records and delay in requesting the OASYS report .
9. I am encouraged that there is now a centralised system (and form) for the SSHD to request OASYS reports from probation although it is not clear the extent to which requests are going through this system. Consent to obtain medical information is sought from FNOs at an induction meeting by Immigration Prison Teams (“IPTs”). Further IPT officers attend prisons and play a key role in obtaining this type of information. However it is not clear what systems are in place to facilitate the obtaining of medical 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 Delays by probation in allocating community offender managers and providing up-to-date OASYS reports
Wider context from the report “8. I am concerned at the potential impact of delays/failure to obtain information in other cases. In Mr Santos’ case there were delays by probation in allocating a community offender manager and providing an up-to-date OASYS report . There were also delays by the SSHD progressing Mr Santos’ case, including issue of the Stage 2 letter, failure to obtain medical records and delay in requesting the OASYS report.
9. I am encouraged that there is now a centralised system (and form) for the SSHD to request OASYS reports from probation although it is not clear the extent to which requests are going through this system. Consent to obtain medical information is sought from FNOs at an induction meeting by Immigration Prison Teams (“IPTs”). Further IPT officers attend prisons and play a key role in obtaining this type of information. However it is not clear what systems are in place to facilitate the obtaining of medical 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 Absence of a prison offender manager specialist model for FNO immigration liaison
Wider context from the report “6. Communication issues between the agencies dealing with immigration and sentence planning may lead to confusion and uncertainty for FNOs.
7. I appreciate that any legal advice for FNOs should be from a legal adviser. I am encouraged that the probation service (who employ community offender managers) is seeking to develop a cohort of probation officers specialising in FNOs and immigration. There are now 201 SPOCs across 12 regions and a hub lead developing this model and leading engagement with the SSHD. There is no such model in the prison in respect of “prison offender managers” who also liaise with the SSHD about FNOs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 facilitate and signpost access to immigration legal advice
Wider context from the report “4. I am concerned as to how access to legal advice is facilitated and signposted.
5. In PFD evidence, I was informed that FNOs (in a similar position to Mr Santos) are now entitled to 30 minutes of free legal advice following a High Court decision in February 2021. In HMP Belmarsh, this entitlement is displayed on a notice in each Houseblock. I am concerned that displaying a notice is insufficient to draw this entitlement to the attention of FNOs. I do not know if this is a wider issue in other prisons. Understanding of immigration status, including appeal and bail procedures and is complex. Access to legal advice is vital to prevent confusion.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 communication between immigration and sentence-planning agencies
Wider context from the report “6. Communication issues between the agencies dealing with immigration and sentence planning may lead to confusion and uncertainty for FNOs.
7. I appreciate that any legal advice for FNOs should be from a legal adviser. I am encouraged that the probation service (who employ community offender managers) is seeking to develop a cohort of probation officers specialising in FNOs and immigration. There are now 201 SPOCs across 12 regions and a hub lead developing this model and leading engagement with the SSHD. There is no such model in the prison in respect of “prison offender managers” who also liaise with the SSHD about FNOs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Persistent misunderstanding of the policy governing OSG officers opening cell doors at night
Wider context from the report “13. In evidence there was a continued misunderstanding that the policy did not apply to Operational Support Grade (OSG) officers and it was understood that they should never open cell doors at night . This was despite the PPO report dated December 2021 (at paragraph 73) requesting this be addressed.
14. The prison stated in PFD evidence that all staff will be instructed as to the policy in terms of opening cell doors at night (which requires a dynamic risk assessment).
15. I remain concerned that this appears to be a longstanding belief held by experienced officers .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 communication of entitlement to free immigration legal advice
Wider context from the report “4. I am concerned as to how access to legal advice is facilitated and signposted.
5. In PFD evidence, I was informed that FNOs (in a similar position to Mr Santos) are now entitled to 30 minutes of free legal advice following a High Court decision in February 2021. In HMP Belmarsh, this entitlement is displayed on a notice in each Houseblock. I am concerned that displaying a notice is insufficient to draw this entitlement to the attention of FNOs. I do not know if this is a wider issue in other prisons. Understanding of immigration status, including appeal and bail procedures and is complex. Access to legal advice is vital to prevent confusion.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Lack of clear systems for obtaining medical information
Wider context from the report “8. I am concerned at the potential impact of delays/failure to obtain information in other cases. In Mr Santos’ case there were delays by probation in allocating a community offender manager and providing an up-to-date OASYS report. There were also delays by the SSHD progressing Mr Santos’ case, including issue of the Stage 2 letter, failure to obtain medical records and delay in requesting the OASYS report.
9. I am encouraged that there is now a centralised system (and form) for the SSHD to request OASYS reports from probation although it is not clear the extent to which requests are going through this system. Consent to obtain medical information is sought from FNOs at an induction meeting by Immigration Prison Teams (“IPTs”). Further IPT officers attend prisons and play a key role in obtaining this type of information. However it is not clear what systems are in place to facilitate the obtaining of medical 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 disseminate and action important learning points
Wider context from the report “10. The SSHD disclosed an Internal report into Mr Santos’ case midway through the Inquest, which was not on his Home Office file. The lawyers representing the SSHD were unaware of this report. The head of FNO Returns Command only became aware of it the preceding week and understood it had been disclosed.
11. The report detailed delays and issues in Mr Santos’ case and the SSHD then made formal admissions of the relevant (non-causative) failures which where recorded by the jury in the Record of Inquest at my direction.
12. This report was dated February 2021 and listed action points for the relevant department. Although I am told that these are now being addressed, I am concerned that important learning points (which could prevent future deaths) were not disseminated and actioned as they should have been.
” 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 Develop a national Foreign National Offender coordination hub to support the interface between probation and the Home Office.
Verbatim wording from the response “To implement a change programme that supports Foreign National Offenders (FNO) nationally, a specific coordination hub has been developed by the Probation Service. Seconded probation practitioners have been allocated to the Home Office to support the work in increasing efficiencies in the interface. Further to the probation specific strand on the joint HMPPS/FNO removal centre taskforce, the seconded members of staff support front line practice and respond to any escalations or obstacles that are brought to their attention.” Source location Response from HM Prison and Probation Services
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 Allocate seconded probation practitioners to the Home Office to support frontline practice and resolve escalated interface obstacles.
Verbatim wording from the response “To implement a change programme that supports Foreign National Offenders (FNO) nationally, a specific coordination hub has been developed by the Probation Service. Seconded probation practitioners have been allocated to the Home Office to support the work in increasing efficiencies in the interface. Further to the probation specific strand on the joint HMPPS/FNO removal centre taskforce, the seconded members of staff support front line practice and respond to any escalations or obstacles that are brought to their attention.” Source location Response from HM Prison and Probation Services
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 an escalation process for risk-information responses outstanding for more than 20 days.
Verbatim wording from the response “The Home Office uses a specific form called ‘Request for Risk Information’ to request an OASys assessment. These are now centrally administered by the FNO coordination hub to ensure that there is a central referral point for the Home Office. The request is then sent directly to the relevant practitioner to action, or the team if the matter is not yet allocated. We have also introduced an escalation process that highlights responses that have not been received within 20 days.” Source location Response from HM Prison and Probation Services
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 Centrally administer Home Office requests for risk information and route them to the relevant practitioner or team.
Verbatim wording from the response “The Home Office uses a specific form called ‘Request for Risk Information’ to request an OASys assessment. These are now centrally administered by the FNO coordination hub to ensure that there is a central referral point for the Home Office. The request is then sent directly to the relevant practitioner to action, or the team if the matter is not yet allocated. We have also introduced an escalation process that highlights responses that have not been received within 20 days.” Source location Response from HM Prison and Probation Services
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reissue night-state cell-unlocking procedures and reinforce them through staff reminders and full staff briefings.
Verbatim wording from the response “We remain committed to ensuring that staff and prisoner safety is a key priority across the prison estate. The prison have re-issued a notice to staff clearly stating the procedures to follow in the event that a cell door needs to be unlocked during the night state. Both officers and OSGs have been reminded that, subject to a dynamic risk assessment being completed, the preservation of life takes precedence over any normal circumstance. This has been highlighted further during full staff briefings.” Source location Response from HM Prison and Probation Services
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Create and resource a learning team to disseminate learning from probation-involved inquests across the probation service and OMiC model.
Verbatim wording from the response “Separately, a new learning team has also been created and resourced by HMPPS to enable learning from probation-involved inquests to be disseminated across the probation service, and included as part of the Offender Management in Custody (OMiC) model of working.” Source location Response from HM Prison and Probation Services
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 and disseminate access to 30 minutes of legally aided legal advice through houseblock posters and custody induction.
Verbatim wording from the response “In October 2021 guidance was provided to all establishments setting out the requirement that immigration detainees be informed about and provided with access to 30 minutes of legally aided legal advice. The operational implementation and support group have ensured that all prisons holding immigration detainees have implemented these instructions. As set out in the report, HMP Belmarsh published this information in the form of a poster on all houseblocks including the first night centre. This information also now forms part of the induction to custody process that all prisoners receive when they first come into custody.” Source location Response from HM Prison and Probation Services
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 Home Office and healthcare provider will respond separately to concerns about foreign national prisoner support and inter-agency communication.
Verbatim wording from the response “You have raised some concerns regarding the management and support of Foreign National prisoners, specifically the signposting and facilitating of access to legal advice and communication between the Home Office, HMPPS and Healthcare. I understand that the Home Office and Practice Plus Group (the healthcare provider at HMP Belmarsh) will be providing a separate response. Further to this, you have raised concern with Operational Support Grades’ (OSG) understanding of the night state policy at HMP Belmarsh.” Source location Response from HM Prison and Probation Services
Open published response
25 Aug 2023 Stephen Weatherley · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 3 Absence of written guidance for suspected drug swallow assessment, referral and monitoring View source Inadequate MOJ oversight and monitoring of recording and retention of data View source Failure to maintain and retain complete contemporaneous records and documents View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Stephen Weatherley · 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 Weatherley died at HMP Thameside from the toxic effects of cocaine and methadone after swallowing a package containing a drug during a prison visit. The report identifies concerns about the visitor being allowed an open visit, inadequate investigation and monitoring after the visit, poor record keeping and data retention, and the absence of written guidance for suspected drug swallows.
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 Absence of written guidance for suspected drug swallow assessment, referral and monitoring
Wider context from the report “Absence of a written policy at HMP Thameside if there is a suspected drug swallow.
15. In 2018, there was no written policy as to what should occur where there may have been a drugs swallow but it had not been seen immediately by staff or on CCTV. That remains the case.
16. In SW’s case, the body scanner had not been installed in 2018 and following a search of SW and review of the CCTV he was returned to the wing (and not taken CSU or healthcare). The jury found that there was insufficient investigation after the visit and a lack of implementation of precautionary measures.
17. I was informed by HMP Thameside on 12th June 2023, that in a similar situation the prisoner would now be scanned using the body scanner. If the prisoner had concealed an item in a bodily orifice he would be taken to CSU. If he had swallowed an item, he would be taken to Healthcare. I was told this is standard practice but is not written down. Further, if a prisoner refused a scan, he would be taken to CSU. The management of the prisoner in CSU would be the subject of an algorithm deployed by Healthcare, which then produced guidance as to monitoring. There would be liaison between Healthcare and CSU to ensure the prisoner was appropriately monitored.
18. At present the system relies upon good communications/decision making between healthcare and discipline staff and individual judgement.
19. I remain concerned as to the absence of written guidance for officers and the risk that if they are not aware of the above “informal” guidance, a prisoner may not be taken to the correct location (CSU or Healthcare) and/or there may not be appropriate monitoring . I appreciate that each situation is fact specific and drafting written guidance may be difficult.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 MOJ oversight and monitoring of recording and retention of data
Wider context from the report “Data recording and retention in HMP Thameside/oversight by MOJ
1. Key documents around decision making by Serco officers in respect of open/closed visits for SW were lost.
2. Record keeping of key events on 23rd and 24th February 2018 was not properly completed by Serco officers on the central system for recording, operated by the MOJ (“PNOMIS”).
3. There were only 3 entries on SW’s PNOMIS record in the 5 months he was at HMP Thameside.
4. The PPO investigator encountered delays in obtaining documents, unclear and incomplete records from HMP Thameside. The decision making around closed visits/reviews was requested by the PPO in September 2018 and had not been provided at the time the PPO report in April 2019, which pre-dated the electronic migration of data in October 2020 (see below).
5. Solicitors representing HMP Thameside informed me on 30 March 2023 that the prison was unable to adduce the 2018 versions of the local standard operating procedures in place at the time of SW’s death (i.e re visits procedures) due to a large IT migration which took place around 18 months prior (October 2020), which resulted in the loss of some historical data saved on their systems.
6. I subsequently requested the underlying decision making around closed visits/review (as I had the PPO before me) and was informed that these documents were no longer available, also lost in the electronic migration.
7. I was then informed (during the Inquest), that material may have been lost due to officers storing it on local desktop computers and not uploading it to the main system.
8. Having expressed concerns about record-keeping and data retention, I heard PFD evidence on 12th June 2023 about a limited internal audit of PNOMIS which revealed concerns over 15% of the records reviewed. I heard evidence that contract managers oversee the contract between the MOJ and Serco, reporting monthly on contract delivery indicators. They do not conduct specific checks on PNOMIS record keeping/audits of the same.
9. I also heard evidence on 12th June 2023 that there remain two systems for record keeping, the Serco system, CMS and the national MOJ system, PNOMIS. CMS requires a layer of officer input (uploading and/or printing off) to ensure retention and distribution. A notice to staff dated 23rd June 2023 reminded them to upload material to CMS.
10. A witness statement from the director of HMP Thameside dated 26th June 2023 further explained the contractual relationship between the MOJ and Serco including the 28 contract delivery indicators. There is also a contractual requirement to ensure compliance with Prison Service Instructions (PSIs) which include PSI 04/2018 which relates to records, information management and retention policy.
11. In this witness statement, the director stated that he had instructed the Serco Assurance Team (independent of the prison team) to conduct a widespread audit of the PNOMIS and Death in Custody files, which will be completed by September 2023. Whilst I am reassured that an independent audit is being conducted, the results are not currently available. SW died in 2018 and the audit was not initiated until June 2023.
12. I accept that there have been improvements. However, given the extent and impact of the deficiencies outlined above, I remain concerned as to whether systems (for both record keeping and retention) have improved sufficiently since 2018.
13. I am also concerned as to the level of oversight and monitoring by the MOJ (having subcontracted to Serco) of recording and retention of data , given that key data was lost, key records were not maintained and the PPO was not provided with documents requested.
14. If key documents are not available/incidents are not recorded contemporaneously, then the PPO and the Inquest process is frustrated. It is more difficult to identify deficiencies and prevent future deaths. Further, if communications are not recorded, there is a risk that relevant factors are not considered when officers are making potentially life-impacting 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 Failure to maintain and retain complete contemporaneous records and documents
Wider context from the report “Data recording and retention in HMP Thameside/oversight by MOJ
1. Key documents around decision making by Serco officers in respect of open/closed visits for SW were lost.
2. Record keeping of key events on 23rd and 24th February 2018 was not properly completed by Serco officers on the central system for recording, operated by the MOJ (“PNOMIS”).
3. There were only 3 entries on SW’s PNOMIS record in the 5 months he was at HMP Thameside.
4. The PPO investigator encountered delays in obtaining documents, unclear and incomplete records from HMP Thameside. The decision making around closed visits/reviews was requested by the PPO in September 2018 and had not been provided at the time the PPO report in April 2019, which pre-dated the electronic migration of data in October 2020 (see below).
5. Solicitors representing HMP Thameside informed me on 30 March 2023 that the prison was unable to adduce the 2018 versions of the local standard operating procedures in place at the time of SW’s death (i.e re visits procedures) due to a large IT migration which took place around 18 months prior (October 2020), which resulted in the loss of some historical data saved on their systems.
6. I subsequently requested the underlying decision making around closed visits/review (as I had the PPO before me) and was informed that these documents were no longer available, also lost in the electronic migration.
7. I was then informed (during the Inquest), that material may have been lost due to officers storing it on local desktop computers and not uploading it to the main system.
8. Having expressed concerns about record-keeping and data retention, I heard PFD evidence on 12th June 2023 about a limited internal audit of PNOMIS which revealed concerns over 15% of the records reviewed. I heard evidence that contract managers oversee the contract between the MOJ and Serco, reporting monthly on contract delivery indicators. They do not conduct specific checks on PNOMIS record keeping/audits of the same.
9. I also heard evidence on 12th June 2023 that there remain two systems for record keeping, the Serco system, CMS and the national MOJ system, PNOMIS. CMS requires a layer of officer input (uploading and/or printing off) to ensure retention and distribution. A notice to staff dated 23rd June 2023 reminded them to upload material to CMS.
10. A witness statement from the director of HMP Thameside dated 26th June 2023 further explained the contractual relationship between the MOJ and Serco including the 28 contract delivery indicators. There is also a contractual requirement to ensure compliance with Prison Service Instructions (PSIs) which include PSI 04/2018 which relates to records, information management and retention policy.
11. In this witness statement, the director stated that he had instructed the Serco Assurance Team (independent of the prison team) to conduct a widespread audit of the PNOMIS and Death in Custody files, which will be completed by September 2023. Whilst I am reassured that an independent audit is being conducted, the results are not currently available. SW died in 2018 and the audit was not initiated until June 2023.
12. I accept that there have been improvements. However, given the extent and impact of the deficiencies outlined above, I remain concerned as to whether systems (for both record keeping and retention) have improved sufficiently since 2018.
13. I am also concerned as to the level of oversight and monitoring by the MOJ (having subcontracted to Serco) of recording and retention of data, given that key data was lost, key records were not maintained and the PPO was not provided with documents requested.
14. If key documents are not available/incidents are not recorded contemporaneously, then the PPO and the Inquest process is frustrated. It is more difficult to identify deficiencies and prevent future deaths. Further, if communications are not recorded , there is a risk that relevant factors are not considered when officers are making potentially life-impacting decisions.
” Open source report
×
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 contractual monitoring, record-retention requirements and death-in-custody plans provide sufficient oversight of records and data retention.
Verbatim wording from the response “I can confirm that I have received a copy of the response from the Director at HMP Thameside which sets out the policies that the prison must adhere to and the contract requirements. To further assist, I can confirm that the contract has several delivery indicators which measure the performance of all aspects of custodial delivery. The prison’s performance is reviewed each month and during quarterly contract reviews. All aspects of the custodial contract are monitored through provider submissions and compliance testing. Each month the provider, Serco, submit evidence that they have complied with all contract delivery indicators (CDIs) and compliance tests are carried out on a monthly basis to test different aspects of the contract which are scored on a RAG (red, amber, green) rating scale for monitoring and improvement purposes.” Source location Response from HM Prison and Probation Service
Open published response
15 Aug 2023 Haik Patrick NIKOLYAN · Prevention of Future Deaths report Buckinghamshire
View report summary
Concerns raised 5 Lack of appropriate resources for maintaining neurodiversity management work View source Insufficient general staffing levels for operating the daily regime, training and responding to individual incidents View source Failure to recruit and retain experienced prison staff, particularly Grade 3 officers View source Access to illicit substances within the prison View source Increasing levels of violence within the prison 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
Haik Patrick NIKOLYAN · 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
Haik Patrick NIKOLYAN committed suicide and was found unresponsive in his cell at HMYOI Aylesbury in the early hours of 11 March 2019. The inquest identified concerns including failures to protect him from harm, withdrawal of depression medication without documented risk assessment or enhanced monitoring, bullying and exploitation, ineffective safeguarding and communication, and inadequate consideration of his Autism Spectrum Disorder.
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 appropriate resources for maintaining neurodiversity management work
Wider context from the report “Some three months further on, my concerns are heightened to the extent that a death may result in a variety of circumstances through the continuing significant issues HMP Aylesbury is encountering in recruitment and retention of experienced prison staff, particularly Grade 3 officers.
Although initial steps are being taken towards implementation of a new neurodiversity plan, including the management of prisoners with autistic traits (pertinent to the circumstances of the death of Haik Nikolyan in 2019) and some recruitment has just taken place, without appropriate resources specifically in this area and within the broader staff cohort, there will be difficulties in maintaining this important work .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 general staffing levels for operating the daily regime, training and responding to individual incidents
Wider context from the report “The evidence heard at this Inquest in July 2023 indicates that general staffing levels are likely to impact upon the operation of the daily regime, training and reaction to individual incidents , against a background of increasing levels of violence and access to illicit substances, resulting from the changing cohort of longer-term and older prisoners within this Category C institution.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 recruit and retain experienced prison staff, particularly Grade 3 officers
Wider context from the report “Some three months further on, my concerns are heightened to the extent that a death may result in a variety of circumstances through the continuing significant issues HMP Aylesbury is encountering in recruitment and retention of experienced prison staff, particularly Grade 3 officers .
Although initial steps are being taken towards implementation of a new neurodiversity plan, including the management of prisoners with autistic traits (pertinent to the circumstances of the death of Haik Nikolyan in 2019) and some recruitment has just taken place, without appropriate resources specifically in this area and within the broader staff cohort, there will be difficulties in maintaining this important work.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Access to illicit substances within the prison
Wider context from the report “The evidence heard at this Inquest in July 2023 indicates that general staffing levels are likely to impact upon the operation of the daily regime, training and reaction to individual incidents, against a background of increasing levels of violence and access to illicit substances , resulting from the changing cohort of longer-term and older prisoners within this Category C institution.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Increasing levels of violence within the prison
Wider context from the report “The evidence heard at this Inquest in July 2023 indicates that general staffing levels are likely to impact upon the operation of the daily regime, training and reaction to individual incidents, against a background of increasing levels of violence and access to illicit substances, resulting from the changing cohort of longer-term and older prisoners within this Category C institution.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide priority recruitment-marketing support to HMP Aylesbury and improve staff engagement channels with the establishment.
Verbatim wording from the response “At national level we are taking all necessary steps to improve the staffing position across the country, and we are seeing the impact of that work. Substantial levels of support has been provided to HMP Aylesbury as one of the highest priority prisons for recruitment marketing. In addition, the Prison Resourcing Communications team are working closely with the establishment to improve their staff engagement channels, including their staff newsletter, to increase staff pride and morale to help reduce attrition.” Source location Response from HM Prison and Probation Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review staffing requirements and redistribute available resources at HMP Aylesbury.
Verbatim wording from the response “To support Aylesbury’s function as a category C trainer prison, a review of all staffing requirements was undertaken which has enabled Governors to review and distribute the resources available more effectively. The staffing position at HMP Aylesbury has notably improved and the now small number of vacancies for Band 3 Officers includes some staff who are currently undergoing training. A number of recruitment initiatives have taken place, with more planned for the coming months, to continue to fill vacancies in other key posts, such as instructors and probation POMs.” 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 Launch a national television and radio recruitment advertising campaign for HMPPS.
Verbatim wording from the response “In September 2023, the Ministry of Justice launched its first ever large-scale TV and radio advert to support recruitment across England and Wales, aiming to attract new recruits to a career in HMPPS, while getting the public to rethink what working in the prison and probation service involves, all under the slogan “An extraordinary job done by someone like you”.” 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 Appoint a Band 6 neurodiversity support manager to raise staff awareness and provide toolkit-based training.
Verbatim wording from the response “This increase in staffing has allowed an improved regime to be offered to all prisoners, and has enabled the expansion of the key work provision, which gives enhanced support to prisoners. HMP Aylesbury have appointed a Band 6 Neurodiversity support manager to raise awareness of neurodiversity among all staff, and to provide training using the neurodiversity toolkit. The reception and induction will also be adapted to make them more accessible for neurodivergent prisoners.” Source location Response from HM Prison and Probation Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the adjudication tariff and process for drug-related incidents, county lines and criminal exploitation.
Verbatim wording from the response “Considerable work continues to be undertaken to reduce the availability and use of drugs within HMP Aylesbury. A National and Group Drug Strategy support visit has included a review of the adjudication tariff and process for drug related incidents including positive MDT results, and a review of county lines and criminal exploitation. Conversations are additionally underway with Public Health and Commissioners to support the strategy of improving staff and prisoner” 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 Reconfigure the safety team by adding Band 5 and Band 4 analyst roles and an additional officer.
Verbatim wording from the response “While levels of violence at the establishment remain low, the safety team has been reconfigured to offer more support to prisoners, adding an operational Band 5, Band 4 Analyst and an extra officer to this team.” 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 Public Health and Commissioners to improve substance-misuse awareness and support drug-supply reduction, demand reduction and recovery.
Verbatim wording from the response “Considerable work continues to be undertaken to reduce the availability and use of drugs within HMP Aylesbury. A National and Group Drug Strategy support visit has included a review of the adjudication tariff and process for drug related incidents including positive MDT results, and a review of county lines and criminal exploitation. Conversations are additionally underway with Public Health and Commissioners to support the strategy of improving staff and prisoner” 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 Continue recruitment initiatives to fill vacancies in instructors, probation POMs and other key posts.
Verbatim wording from the response “To support Aylesbury’s function as a category C trainer prison, a review of all staffing requirements was undertaken which has enabled Governors to review and distribute the resources available more effectively. The staffing position at HMP Aylesbury has notably improved and the now small number of vacancies for Band 3 Officers includes some staff who are currently undergoing training. A number of recruitment initiatives have taken place, with more planned for the coming months, to continue to fill vacancies in other key posts, such as instructors and probation POMs.” 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 Staffing at HMP Aylesbury has notably improved, with only a small number of Band 3 officer vacancies, some involving staff undergoing training.
Verbatim wording from the response “To support Aylesbury’s function as a category C trainer prison, a review of all staffing requirements was undertaken which has enabled Governors to review and distribute the resources available more effectively. The staffing position at HMP Aylesbury has notably improved and the now small number of vacancies for Band 3 Officers includes some staff who are currently undergoing training. A number of recruitment initiatives have taken place, with more planned for the coming months, to continue to fill vacancies in other key posts, such as instructors and probation POMs.” Source location Response from HM Prison and Probation Service
Open published response
14 Jul 2023 Sean Anthony Heeney · Prevention of Future Deaths report Northamptonshire
View report summary
Concerns raised 1 Failure to maintain a first-floor medical-emergency extrication plan for residents unable or unwilling to leave View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Sean Anthony Heeney · 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
Sean Anthony Heeney was found unresponsive at Bridgewood House on 22 September 2019 and died in hospital on 26 September 2019 after suffering cardiac arrest during efforts to extricate him from the building. The principal concerns were delays caused by the lack of a clear extrication plan, the building’s restrictive layout, and the absence of a plan for evacuating a person unable or unwilling to leave during a medical emergency. The inquest narrative also stated that the initial emergency call was incorrectly categorised and that ambulance staff did not properly appreciate the seriousness and urgency of his condition.
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 maintain a first-floor medical-emergency extrication plan for residents unable or unwilling to leave
Wider context from the report “The evidence suggested a lack of a clear or settled plan amongst the EMAS personnel and police officers as to how Mr Heeney was to be extricated. This caused a delay in removing Mr Heeney to hospital.
Whilst I recognise that any extrication is unlikely to be something done by the Approved Premises staff on their own or at all, I am concerned that Bridgewood House did not and still does not have a plan on how to extricate from the first-floor of the building a person who is unable and/or unwilling to leave in the case of a medical emergency . In this respect, I note the following:
1. The layout of the building and the restrictions which that creates was and remains a known issue: a former manager of Bridgewood House described how it did not take “any residents with mobility issues, because of the stairs”.
2. HMPPS have identified a requirement for Personal Emergency Evacuation Plans. I was referred to the ‘Approved Premises Safe Working Practice Document’ for Bridgewood House which provides:
“Personal Emergency Evacuation Plans (PEEP) must be put in place for any building user who would encounter a problem and need assistance in exiting the building in an emergency. Staff must be aware of individual residents and colleagues who are on PEEP. Separate PEEP forms are for both staff and residents.”
3. HMPPS have properly identified that individuals recently released from prison have a heightened risk of accidental overdose as they may have lost tolerance to drugs which they had previously used. This is reflected in the induction paperwork provided to residents at Approved Premises.
4. It is to be anticipated that residents within Approved Premises may be more reluctant to cooperate with emergency service personnel, in particular the police. This may make extrication more difficult.
5. It is to be anticipated that residents who have overdosed may be administered Naloxone. This is reflected in HMPPS’ roll-out of Naloxone to all Approved Premises since Mr Heeney’s death. As witnesses explained, a known side-effect of Naloxone is increased agitation.
” 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 Consult local emergency services to prepare a recorded plan for evacuating medically incapacitated or unwilling people from Bridgewood House.
Verbatim wording from the response “In response, please be assured that Bridgewood House Approved Premises is consulting with the local emergency services on the preparation of a plan to deal with evacuation from the building in a medical emergency. As you helpfully identified the extrication itself is something that would not be undertaken by the Approved Premises staff but it is accepted that a clearly recorded understanding between the agencies involved in such a procedure should ensure a successful evacuation should a similar situation arise in the future.” 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 Approved Premises staff will not undertake medical-emergency extrication; local emergency services are responsible for this evacuation work.
Verbatim wording from the response “In response, please be assured that Bridgewood House Approved Premises is consulting with the local emergency services on the preparation of a plan to deal with evacuation from the building in a medical emergency. As you helpfully identified the extrication itself is something that would not be undertaken by the Approved Premises staff but it is accepted that a clearly recorded understanding between the agencies involved in such a procedure should ensure a successful evacuation should a similar situation arise in the future.” Source location Response from HM Prison and Probation Service
Open published response
3 Jul 2023 Liam Ryan Wayne Bentley · Prevention of Future Deaths report Mid Kent and Medway
View report summary
Concerns raised 1 Insufficient prison staffing levels View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Liam Ryan Wayne Bentley · 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 Ryan Wayne Bentley was a serving prisoner at HMP Swaleside who had a history of self-harm and expressed fears about other prisoners and suicidal thoughts. He later took his own life, although his intention was unclear. The report identified concerns about inadequate psychological support, failures in self-harm monitoring and care planning, ineffective communication, and staff shortages and training gaps.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Insufficient prison staffing levels
Wider context from the report “(1) There was evidence from prison staff from which it was concluded by the jury that the safety of deceased was compromised as a result in staff shortages
(2) The current complement of Band 2 Operational Support Group staff is 71% this is predicted to further reduce to 54%, the current complement of Band 3 Prison Officers is 68% this is predicted to further reduce to 46%.
” 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 Continue monitoring staffing levels and provide short-term tactical staffing support through overtime and detached-duty staff.
Verbatim wording from the response “Ensuring that prisons are sufficiently resourced is fundamental to ensuring that we are delivering quality outcomes for offenders. We continue to monitor staffing levels at HMP Swaleside and, as in other establishments, look to provide short-term tactical support where possible. Where establishments feel that their staffing levels will affect stability or regime, there are a number of ways they can maximise the use of their own resource and seek support from other establishments in the short term, through processes managed nationally at agency level. These include overtime payments and support via detached duty staff from other prisons.” Source location Response from HM Prison and Probation Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Support recruitment of Armed Forces veterans and their spouses into frontline roles through Advance into Justice.
Verbatim wording from the response “HMP Swaleside is supported by recruitment interventions including Advance into Justice which supports Armed Forces veterans and their spouses into frontline roles; Prison Officer ‘Futures’ where new recruits are recruited directly to establishments with a strong track record of recruitment but, for the first 23 months, they will be expected to be deployed at a named establishment elsewhere to temporarily reduce their vacancy position; and our National First Time Officer scheme which recruits officers nationally sending them to a prison which has difficulty recruiting, with additional financial support. We also use locally targeted PR activity, including a new recruitment ‘landing page’ specific to the prison, where prospective staff can view videos of frontline officers from Swaleside to understand what it is like to work there.” 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 Recruit officers nationally through the National First Time Officer scheme and deploy them to prisons experiencing recruitment difficulty with additional financial support.
Verbatim wording from the response “HMP Swaleside is supported by recruitment interventions including Advance into Justice which supports Armed Forces veterans and their spouses into frontline roles; Prison Officer ‘Futures’ where new recruits are recruited directly to establishments with a strong track record of recruitment but, for the first 23 months, they will be expected to be deployed at a named establishment elsewhere to temporarily reduce their vacancy position; and our National First Time Officer scheme which recruits officers nationally sending them to a prison which has difficulty recruiting, with additional financial support. We also use locally targeted PR activity, including a new recruitment ‘landing page’ specific to the prison, where prospective staff can view videos of frontline officers from Swaleside to understand what it is like to work there.” 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 Deliver the 2023/24 pay award, including specified increases for operational support grades and prison officers.
Verbatim wording from the response “The 2023/24 pay award will deliver a pay increase of £2,000 for our lowest paid staff, Band 2 Operational Support Grades, as well as a 7% pay increase for Band 3-5 prison officers. HMP Swaleside is also in receipt of a market supplement, which means Band 3 officers working at the prison receive more pay in order to attract and retain more staff. We hope that this significant investment, which builds on progress from last year’s pay award, will have a positive impact on recruitment and retention.” 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 Provide a market supplement for Band 3 officers working at HMP Swaleside to support recruitment and retention.
Verbatim wording from the response “The 2023/24 pay award will deliver a pay increase of £2,000 for our lowest paid staff, Band 2 Operational Support Grades, as well as a 7% pay increase for Band 3-5 prison officers. HMP Swaleside is also in receipt of a market supplement, which means Band 3 officers working at the prison receive more pay in order to attract and retain more staff. We hope that this significant investment, which builds on progress from last year’s pay award, will have a positive impact on recruitment and retention.” 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 locally targeted recruitment activity, including a Swaleside-specific recruitment landing page featuring frontline officer videos.
Verbatim wording from the response “HMP Swaleside is supported by recruitment interventions including Advance into Justice which supports Armed Forces veterans and their spouses into frontline roles; Prison Officer ‘Futures’ where new recruits are recruited directly to establishments with a strong track record of recruitment but, for the first 23 months, they will be expected to be deployed at a named establishment elsewhere to temporarily reduce their vacancy position; and our National First Time Officer scheme which recruits officers nationally sending them to a prison which has difficulty recruiting, with additional financial support. We also use locally targeted PR activity, including a new recruitment ‘landing page’ specific to the prison, where prospective staff can view videos of frontline officers from Swaleside to understand what it is like to work there.” 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 Recruit new officers through the Prison Officer Futures scheme and deploy them temporarily to establishments with staffing vacancies.
Verbatim wording from the response “HMP Swaleside is supported by recruitment interventions including Advance into Justice which supports Armed Forces veterans and their spouses into frontline roles; Prison Officer ‘Futures’ where new recruits are recruited directly to establishments with a strong track record of recruitment but, for the first 23 months, they will be expected to be deployed at a named establishment elsewhere to temporarily reduce their vacancy position; and our National First Time Officer scheme which recruits officers nationally sending them to a prison which has difficulty recruiting, with additional financial support. We also use locally targeted PR activity, including a new recruitment ‘landing page’ specific to the prison, where prospective staff can view videos of frontline officers from Swaleside to understand what it is like to work there.” Source location Response from HM Prison and Probation Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce a colleague mentor scheme supporting staff new to the prison service during their early careers.
Verbatim wording from the response “In addition to short-term support, we are seeking to improve the staffing position at HMP Swaleside through a range of interventions across pay, recruitment and retention. This” Source location Response from HM Prison and Probation Service
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The cited staffing figures do not represent HMP Swaleside’s current or future staffing position because recruitment, retention and deployment actions are underway.
Verbatim wording from the response “Firstly, I thought it might be helpful to clarify the figures on staffing levels that you have referred to in your report. HMPPS carry out a lot of work to understand reasonable worst case and likely staffing scenarios for prisons, and look to ensure that action is taken to intervene where the recruitment and retention positions look challenging. This includes deploying staff from other sites to supplement the staffing group directly employed at the prison. These figures do not represent the current or future staffing position at HMP Swaleside, in part due to the actions undertaken locally and nationally to improve recruitment and retention.” Source location Response from HM Prison and Probation Service
Open published response
Concerns raised 1 Lack of available mouth protection for resuscitation View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Anthony George Smith · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Anthony George Smith was found hanging in his cell at HMP Preston on 4 May 2022 while suffering an acute relapse of schizophrenia, and officers commenced resuscitation. The report raised concerns that mouth-to-mouth resuscitation was performed without available mouth protection, creating risks of blood-borne virus transmission and potentially discouraging rescue breaths, and noted the need for readily accessible protection masks.
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 available mouth protection for resuscitation
Wider context from the report “(1) An officer attempting resuscitation carried out mouth to mouth resuscitation without the safeguard of mouth protection which was not available in the prison at the time . Mr Smith was a regular drug user who on occasions injected drugs. Performing mouth to mouth resuscitation carried with it the risk of transmission of blood born viruses with possible fatal consequences .
(2) The lack of available protection not only carried with it a risk to those who performed resuscitation but potentially also to the person suffering a cardiac arrest in that without protection the would-be resuscitator might decline to provide rescue breaths
” 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 staff guidance explaining face-shield locations and the importance of using them during CPR.
Verbatim wording from the response “At HMP Preston, face shields have been purchased and added to the existing first aid boxes on all residential units and will be monitored by the Health and Safety Team. A Notice to Staff was also issued in June 2023 to advise staff of the location of the face shields and the importance of using these when administering CPR.” 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 Provide resuscitation face shields in first-aid boxes across all HMP Preston residential units.
Verbatim wording from the response “At HMP Preston, face shields have been purchased and added to the existing first aid boxes on all residential units and will be monitored by the Health and Safety Team. A Notice to Staff was also issued in June 2023 to advise staff of the location of the face shields and the importance of using these when administering CPR.” 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 Monitor HMP Preston face shields and replenish them when required.
Verbatim wording from the response “As you are aware, the First Aid Policy Framework is currently under review and is due to be re-issued by August 2023. The revised policy document will include instructions on the use of face shields including the requirement for all first aid kits in prisons to contain resuscitation face shields and for these to be monitored and replenished when required. The policy also emphasises the training requirements for Emergency First Aid and First Aid at Work, including the importance of using the face masks correctly and of these being available at all times.” Source location Response from HM Prison and Probation Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reissue the First Aid Policy Framework with face-shield requirements for prison first-aid kits and related CPR guidance.
Verbatim wording from the response “As you are aware, the First Aid Policy Framework is currently under review and is due to be re-issued by August 2023. The revised policy document will include instructions on the use of face shields including the requirement for all first aid kits in prisons to contain resuscitation face shields and for these to be monitored and replenished when required. The policy also emphasises the training requirements for Emergency First Aid and First Aid at Work, including the importance of using the face masks correctly and of these being available at all times.” Source location Response from HM Prison and Probation Service
Open published response
2 Jun 2023 Andrew DEAN · Prevention of Future Deaths report East Sussex
View report summary
Concerns raised 2 Lack of clearly defined processes for new prisoners to make first contact with family members when first-night contact does not take place View source Lack of clearly defined processes for logging and handling safety-related incoming calls to the central switchboard from family members View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Andrew DEAN · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 26 March 2021, Andrew Dean was found with a ligature around his neck in a cell at HMP Lewes and was declared dead later that morning. The concerns related to the lack of clearly defined processes for ensuring that new prisoners could successfully make first contact with family members and for logging and responding to incoming calls from family members concerned about a prisoner’s safety or requesting a welfare check.
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 clearly defined processes for new prisoners to make first contact with family members when first-night contact does not take place
Wider context from the report “I am concerned that there are no clearly defined processes to ensure that new prisoners can successfully make first contact with family members (when this does not take place on the first night) and for logging and handling incoming calls to the central switchboard from family members with concerns about a prisoner’s safety and/or requesting a welfare check.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 clearly defined processes for logging and handling safety-related incoming calls to the central switchboard from family members
Wider context from the report “I am concerned that there are no clearly defined processes to ensure that new prisoners can successfully make first contact with family members (when this does not take place on the first night) and for logging and handling incoming calls to the central switchboard from family members with concerns about a prisoner’s safety and/or requesting a welfare check .
” 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 Revise national policy to require continued first-call facilitation until a successful family call is completed.
Verbatim wording from the response “Following evidence heard at the inquest you have raised two concerns which I will address in turn. Your first concern is about the process for ensuring that new prisoners can successfully make first contact with family members. The national policy provides for an exception to the monitoring arrangements that must be put in place for prisoner calls for “at least one initial phone call to be made by prisoners on the first night in Reception, if available, or else in the first night location, in line with paragraph 2.42 of PSI 07/2015 – Early Days in Custody”, and requires Governors to make local arrangements to facilitate this. I acknowledge that the policy does not cover what to do when contact cannot be made on the first night, but it is clearly within the spirit of the policy that this exception should continue to apply until at least one successful call has been facilitated.” 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 Inform operational staff and publish a notice requiring welfare-related calls to be recorded, immediately passed to the duty officer and acted on through a welfare check.
Verbatim wording from the response “In the meantime, the prison have informed Operational Support Grade (OSG) staff that all calls received from family members, friends and members of the public regarding the welfare of a prisoner must be recorded within the Comms log and the information must be passed to the duty Orderly Officer or the night Orderly Officer immediately so that a welfare check can be carried out. There should always be an OSG working in the Comms room, however, in case of unforeseen circumstances, a notice to all staff has also been published setting out the actions staff must take when a call is received regarding the welfare of a prisoner.” 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 Fund and roll out the pilot recording and response processes, including electronic call logging, with Pact support, group-lead upskilling and learning dissemination across prisons.
Verbatim wording from the response “In light of this we are providing additional funding to Pact in 2023-24 and working with them to roll out the processes developed during the pilot to all prisons in England and Wales by March 2024. This includes the electronic logging of calls. Pact will be providing on site support to eight (geographically dispersed) prisons and the Group Safety Leads from the relevant and neighbouring prison groups will attend these prisons alongside Pact staff and participate in the upskilling sessions that they offer using the toolkit developed during the pilot, so that they are equipped to share the learning and to support the prisons in their groups that will not be receiving direct support from Pact. HMP Lewes will be one of the prisons receiving on site support from Pact – this is scheduled for December 2023.” Source location Response from HM Prison and Probation Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a family-engagement safety toolkit and pilot electronic logging of safer-custody concerns in prisons.
Verbatim wording from the response “In order to rectify this from 2020-22 we funded the charity Pact (through our innovations grant competition) to work with a number of pilot prisons to develop a toolkit of guidance and resources to support consistent and effective family engagement in safety processes, including recording, responding to and acting on safer custody concerns. Electronic logging of safer custody concerns was piloted in three prisons, and the more robust recording process produced significant improvements in recording and an increase in the number and proportion of calls from families that are returned.” 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 reception and first-night checklist to record initial calls, reasons for non-completion, remedial actions and next-day retries.
Verbatim wording from the response “I have been assured by the Governor of HMP Lewes that there is now a specific checklist in use for reception and first night processes which includes ensuring that an initial phone call is given to all new arrivals before they are located onto a residential wing. The checklist includes a space to record the reasons why an action has not been completed and what will be done to rectify it. If a prisoner is unable to make their initial phone call or if the call is missed or unanswered, another phone call is facilitated the following day.” Source location Response from HM Prison and Probation Service
Open published response
Concerns raised 5 Failure of ACCT audits to identify inadequate document completion View source Lack of certified Safer Cells for managing ligature risk View source Incomplete information sharing between healthcare and prison security staff View source Failure to eliminate or reduce ligature points in cells used for prisoners at risk of self-harm View source Failure to provide adequate ACCT training and refresher training for all relevant staff 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
Thomas Victor HUNTLEY · 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
Thomas Victor Huntley died in HMP Winchester after he was found unresponsive in his cell on 28 May 2020, following a planned act intended to end his life. The inquest identified concerns about missing and inadequately recorded risk information, failures in ACCT documentation and risk assessment, inadequate observations, information sharing between prison and healthcare staff, and ligature risks in cells.
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 ACCT audits to identify inadequate document completion
Wider context from the report “The second relates to the quality and effectiveness of ACCT audits . We heard evidence that ACCT documents are reviewed annually. The case manager mentioned above advised that he had not received any adverse feedback about the quality of his ACCT documents and no issues with them had been identified. Given the inadequate nature of the ACCT document opened on Mr Huntley and apparent lack of understanding about completing the documents the quality of the audits is brought into question .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 certified Safer Cells for managing ligature risk
Wider context from the report “The final area of concern is the lack of certified Safer Cells at HMP Winchester . The inquest heard evidence that these had either never existed at HMP Winchester or had not done so for many years. The evidence from prison governors was that, generally speaking within the prison estate, they were not used or proved too hard to maintain to the certified standard . However certified Safer Cells is still referred to in PSI 64/2011 as a means of managing risk from ligatures . It was heard in evidence that HMP Winchester experience high levels of self-harm and suicide and yet it did not appear that consideration had been given recently to introducing these. Those representing the HMPSS at the were invited to provide information about the status and use of safer certified cells across the prison estate. No such information has been forthcoming.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Incomplete information sharing between healthcare and prison security staff
Wider context from the report “Information sharing.
In evidence it was clear that the ACCT document was the only written document used for sharing information between the healthcare staff employed by the NHS trust and the prison security staff. Healthcare staff record and share their information within SystemOne which the prison security staff do not have access to. Prison security staff record information within NOMIS which healthcare staff do not have access to.
Evidence from witnesses revealed that these information systems are not necessarily fully reviewed for relevant information prior to attending ACCT meetings .
In addition a decision relating to Mr Huntley’s care (i.e. the move to a different cell) was taken by healthcare staff at their own meeting when they did not have the benefit of information available to prison staff.
████████ of HMP Winchester informed me that a Safety Intervention Meeting was now carried out weekly, chaired by a Senior Governor and attended by representatives of the prison, physical and mental health care providers and the probation service. This meeting covers each person subject to an ACCT and any relevant information is share via the ACCT case manager, NOMIS and the multi disciplinary team. ████████ could not assist me with whether this was a HMP Winchester initiative or had a wide application across the prison estate.
My concern is therefore that the current procedures and policies for sharing information are incomplete or not fully complied with . This renders the information which separate teams make decisions about a prisoner incomplete and increases the risk that important factors are not considered.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 eliminate or reduce ligature points in cells used for prisoners at risk of self-harm
Wider context from the report “Cells
At HMP Winchester within the area, considered and referred to by most healthcare and prison staff, as the ‘mental health’ cells there are 2 cells which are not equipped in a way to reduce the amount of available ligature points.
It was clear from the evidence of the healthcare staff at the MDT meeting on the 28/05/2020 that they did not consider the contents of the cell when deciding to move Mr Huntley to the ‘mental health cells’ simply due to the fact he was on an ACCT. I heard evidence that the policy of CNWL has now changed and that a cell move risk assessment must now be carried out and that there is now a revised ligature audit process. HMP Winchester informed me that there is now an annual ligature audit carried out in conjunction with the new healthcare provider at that establishment. In addition I was informed that all telephone points in the ‘mental health cells’ at HMP Winchester have now been removed and placed outside the cells. These are welcome developments.
However at inquest those representing the HMPPS could not inform me whether all telephone points within cells designed for use by those at risk of self harm across the prison estate had been removed. Nor was any evidence available as to what consideration had been given to reducing the risk of the telephone points by design of the points themselves or the manner of their installation. Those representing were invited to provide this information after the hearing but have not done so.
I am concerned that telephone points which provide a ligature point may remain within cells which prison and health care staff consider to be suitable for use by those at risk of self harm .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 adequate ACCT training and refresher training for all relevant staff
Wider context from the report “This leads me to have 2 concerns:
The first regards the provision and quality of ACCT training and refresher training given this evidence was given some 2 years after the death of Mr Huntley and well after the disruptions brought about by the Covid-19 pandemic.
I also heard evidence that despite an ACCT being a ‘whole prison’ document (which can and should be opened by any member of staff) training was not mandatory for non-security staff .
In 2019 there was no joint training for prison and healthcare staff on the use of ACCT documents . I am informed by CNWL that under ACCT v6 (which has been in force since July 2021) joint training is provided and for this is reassuring. However I understand that the frequency of this training is determined in relation to operational capacity at individual establishment level . This is of concern given the evidence from witnesses at this inquest some 20 months after this version came into force.
” 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 Review ligature-resistant cell standards and their use in supporting prisoners in crisis.
Verbatim wording from the response “The final concern raised relates to ligature points in cells. HMPPS is currently undertaking a review of ligature-resistant cells, which have been designed to eliminate ligature points as far as possible. The review has included the cell 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. At this point it is too early to say what new rules may be introduced, such as setting the frequency of maintenance, although we do recognise that cells are subject to constant wear and tear and need frequent attention to keep them up to standard.” Source location Response from HM Prison and Probation Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate an accountability system for ACCT quality assurance, feeding findings back to staff and rectifying serious concerns.
Verbatim wording from the response “assurance checks take place at three main stages. The first takes place within 48 hours from the opening of the ACCT, conducted by the Safety Team, assessing the effectiveness of the immediate steps taken and quality of the documentation. The second check is by the Custodial Manager who checks the ongoing record and the case reviews, ensuring that entries are detailed and meaningful, and whether previously identified actions or identified concerns continue to be taken into account and built on. Following ACCT closure, the Safety Team then review the full ACCT document including the seven day post closure monitoring procedure and the post closure reviews.” 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 Deliver monthly ACCT v6 and SASH training and awareness sessions, supported by a monitored staff training plan.
Verbatim wording from the response “It is essential that ACCT Version 6 (v6) procedures are understood and undertaken by all members of staff working within prisons, including healthcare colleagues, and that staff feel confident in recognising an increase in risk and are aware of the need to record all required information within the ACCT document, including any triggers. ACCT v6 and SASH training includes guidance on understanding and assessing the risks and triggers of self-harm, the ACCT process and supporting individuals who self-harm while they are subject to monitoring.” 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 It is currently too early to determine whether new ligature-resistant cell maintenance rules should be introduced.
Verbatim wording from the response “The final concern raised relates to ligature points in cells. HMPPS is currently undertaking a review of ligature-resistant cells, which have been designed to eliminate ligature points as far as possible. The review has included the cell 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. At this point it is too early to say what new rules may be introduced, such as setting the frequency of maintenance, although we do recognise that cells are subject to constant wear and tear and need frequent attention to keep them up to standard.” 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 multidisciplinary meetings, briefing sheets and observation books are considered sufficient to share necessary prisoner safety information.
Verbatim wording from the response “While SystmOne, the electronic system used by healthcare staff to record medical information cannot be accessed by operational staff for reasons of medical confidentiality, the appropriate sharing of information is encouraged through a range of methods, for example the morning operational meeting is multi-disciplinary and allows all those working with individuals to provide updates and ensure necessary information is shared. The Daily Briefing sheet and wing observation books are also vital tools to ensure all staff are aware of concerns regarding a prisoner.” 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 Operational staff cannot access healthcare records because medical confidentiality prevents direct access to SystmOne.
Verbatim wording from the response “While SystmOne, the electronic system used by healthcare staff to record medical information cannot be accessed by operational staff for reasons of medical confidentiality, the appropriate sharing of information is encouraged through a range of methods, for example the morning operational meeting is multi-disciplinary and allows all those working with individuals to provide updates and ensure necessary information is shared. The Daily Briefing sheet and wing observation books are also vital tools to ensure all staff are aware of concerns regarding a prisoner.” Source location Response from HM Prison and Probation Service
Open published response
12 May 2023 Angela Vanessa CRADDOCK · Prevention of Future Deaths report Cheshire
View report summary
Concerns raised 3 Failure to conduct pre-sentence or post-sentence review View source Failure to include restraining order breach information in OASys risk assessments and prison recall reports and reviews View source Failure to ensure receipt of restraining order conditions by relevant staff View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Angela Vanessa CRADDOCK · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Angela Vanessa Craddock died on 11 April 2018 after an offender attended her address and inflicted survivable injuries. Concerns included failures to identify and share information about breaches of a restraining order, incomplete risk assessment and recall information, and ineffective deployment of police resources to enforce the recall notice.
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 conduct pre-sentence or post-sentence review
Wider context from the report “The offender had not been subject of any pre-sentence or post sentence review following conviction on 19 February 2018 for possession of a knife and a section 39 assault on Angela Craddock. The offender was sentenced to 6 months imprisonment and the Restraining order was granted for 12 months.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 include restraining order breach information in OASys risk assessments and prison recall reports and reviews
Wider context from the report “During the 39 days between conviction and release the offender phoned Angela Craddock on 160 occasions. Most of the calls did not connect. The offender also wrote several letters to Angela Craddock from prison in breach of the Restraining Order.
Details of the Restraining Order were sent to HMP Altcourse and on receipt a paper copy of the conditions were placed in an envelope to be delivered to the Public Protection Department. This was never received so the relevant staff were not aware of the Restraining Order.
Consequently, upon release on licence the community rehabilitation service were unaware of the breaches of the Restraining Order and were unable to include this information in the OASys risk assessment or the prison recall report and review , ultimately sent on to the police for the enforcement of the recall notice.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 receipt of restraining order conditions by relevant staff
Wider context from the report “During the 39 days between conviction and release the offender phoned Angela Craddock on 160 occasions. Most of the calls did not connect. The offender also wrote several letters to Angela Craddock from prison in breach of the Restraining Order.
Details of the Restraining Order were sent to HMP Altcourse and on receipt a paper copy of the conditions were placed in an envelope to be delivered to the Public Protection Department. This was never received so the relevant staff were not aware of the Restraining Order.
Consequently, upon release on licence the community rehabilitation service were unaware of the breaches of the Restraining Order and were unable to include this information in the OASys risk assessment or the prison recall report and review, ultimately sent on to the police for the enforcement of the recall notice.
” 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 Consider thematic inspection recommendations and prepare an action plan addressing them, including assessment, planning and sentence delivery.
Verbatim wording from the response “In addition to the specific responses set out above, it may be of assistance for you to note that HM Inspectorate of Probation has just published a thematic inspection of work undertaken, and progress made, by the Probation Service to reduce the incidence of domestic abuse and protect victims. This includes a number of recommendations for both HMPPS and the Probation Service and will be considered with care and attention and an action plan prepared to respond to the recommendations. Of particular note, the Report includes sections on assessment and planning and sentence delivery which are relevant to the issues of concern you have raised and learning from the specific issues you have raised will be taken into consideration in the preparation of an action plan.” Source location Response from HM Prison and Probabtion 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 Improve information sharing among justice agencies so sentencers receive relevant information, assessments and advice.
Verbatim wording from the response “Since this sentencing exercise took place, Cheshire HMCTS has introduced Dedicated Domestic Abuse Courts (DDAs) to deal specifically with domestic abuse related offences. HMCTS, the CPS, and Cheshire Police and Probation Services are working together to improve information sharing and to ensure that Sentencers have all the relevant and necessary information, assessments and advice to deal appropriately with these cases in Court. Cheshire Probation provides a dedicated Court Duty Officer to work in the DDA Court each day to ensure all necessary enquiries are made and sufficiently focused and detailed reports for sentencing purposes are provided.” Source location Response from HM Prison and Probabtion Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate a single Probation Service to simplify information sharing between releasing prisons and receiving probation areas.
Verbatim wording from the response “At the relevant time, the post sentence supervision was being delivered by the Cheshire & Greater Manchester Community Rehabilitation Company Limited (CRC) and the separation of the delivery of probation supervision had added to the complexity of arrangements to share information between prisons and probation. The CRCs ceased to hold contracts to deliver probation services on the 25th June 2021 and there is now one Probation Service. This has simplified and therefore improved the sharing of information between releasing prisons and the receiving probation service area.” Source location Response from HM Prison and Probabtion 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 Provide a dedicated Probation Court Duty Officer daily in each Dedicated Domestic Abuse Court.
Verbatim wording from the response “Since this sentencing exercise took place, Cheshire HMCTS has introduced Dedicated Domestic Abuse Courts (DDAs) to deal specifically with domestic abuse related offences. HMCTS, the CPS, and Cheshire Police and Probation Services are working together to improve information sharing and to ensure that Sentencers have all the relevant and necessary information, assessments and advice to deal appropriately with these cases in Court. Cheshire Probation provides a dedicated Court Duty Officer to work in the DDA Court each day to ensure all necessary enquiries are made and sufficiently focused and detailed reports for sentencing purposes are provided.” Source location Response from HM Prison and Probabtion Service
Open published response
2 Feb 2023 Jason Anthony Williams · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 4 Failure to issue Governor notices in response to increased psychoactive substance risks View source Lack of specific and dedicated guidance for defining and caring for vulnerable prisoners View source Inadequate quantity and quality of prison staff record keeping on NOMIS View source Failure of the keyworker programme to operate as planned View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jason Anthony Williams · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Jason Anthony Williams was found unresponsive in his cell at HMP Guys Marsh on 31 July 2020, and his death was confirmed by paramedics. The report states that synthetic cannabinoid intoxication was the medical cause of death and that he had deliberately taken drugs without intending fatal consequences. Concerns included inadequate guidance on vulnerable prisoners, shortcomings in the keyworker programme and NOMIS record keeping, and the absence of a Governor notice about increased psychoactive-substance risks.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to issue Governor notices in response to increased psychoactive substance risks
Wider context from the report “iv. A Governor notice was not issued in the time leading up to Jason’s death to prisoners or staff around the concerns regarding access to, and the impact of using, psychoactive substances . I request that consideration is given to a review being undertaken by HMP Guys Marsh as to when such notices should be issued, particularly in relation to increased risks to prisoners around drug use.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Lack of specific and dedicated guidance for defining and caring for vulnerable prisoners
Wider context from the report “i. There is a lack of specific and dedicated national guidance to prison and healthcare staff on how to define and care for vulnerable prisoners. I would request that consideration is given to producing national guidance on this, to also include guidance on addressing self-neglect .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Inadequate quantity and quality of prison staff record keeping on NOMIS
Wider context from the report “iii. The quantity and quality of record keeping by prison staff at HMP Guys Marsh on NOMIS . I request that consideration is given to providing refresher training to prison staff on record keeping to cover the importance of records and their contents, and the required regularity of recording.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure of the keyworker programme to operate as planned
Wider context from the report “ii. The current keyworker programme is not working as planned at HMP Guys Marsh and there was reference to this also being reflected nationally . I would request that consideration is given to a review being undertaken of the keyworker programme within the whole prison estate, and also specifically at HMP Guys Marsh.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and develop the current key-work and OMiC sentence-management model using evidence, data and learning to improve safety and outcomes.
Verbatim wording from the response “Key work is the foundation that supports prison safety by building relationships, and promoting opportunities for rehabilitation. While the Covid pandemic and staffing pressures have had a particularly negative impact on the key worker scheme across the prison estate, we are committed to ensuring that key work is fully reinstated across the male closed estate. With this in mind, the national Offender Management in Custody (OMiC) team will use evidence, data and learning to review and develop the current key work model to maximise the opportunity to deliver better outcomes directly associated with safety and reducing reoffending. This will include reviewing key work and OMiC sentence management, exploring ways in which the current delivery model can be made more flexible to better support delivery, taking into consideration different prison functions and prisoner cohorts.” Source location Response from HM Prison & Probation Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Fully reinstate key work across the male closed prison estate.
Verbatim wording from the response “Key work is the foundation that supports prison safety by building relationships, and promoting opportunities for rehabilitation. While the Covid pandemic and staffing pressures have had a particularly negative impact on the key worker scheme across the prison estate, we are committed to ensuring that key work is fully reinstated across the male closed estate. With this in mind, the national Offender Management in Custody (OMiC) team will use evidence, data and learning to review and develop the current key work model to maximise the opportunity to deliver better outcomes directly associated with safety and reducing reoffending. This will include reviewing key work and OMiC sentence management, exploring ways in which the current delivery model can be made more flexible to better support delivery, taking into consideration different prison functions and prisoner cohorts.” Source location Response from HM Prison & Probation Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate a weekly multidisciplinary Restrict Supply Tasking Group to share drug-ingress information and identify potentially dangerous substances.
Verbatim wording from the response “In respect of your last concern, HMP Guys Marsh have introduced a new weekly meeting (Restrict Supply Tasking Group) which is attended by a multi-disciplinary team. The purpose of this meeting is to discuss and share information regarding the drug ingress into the prison, and to identify any specific strains and substances that are potentially dangerous. If the risks identified require further action, a Governor’s Notice To Staff and a prisoners’ notice highlighting the risks and concerns will be issued. Further to this, known prolific substance misuse users will be issued with harm minimisation guidance and support.” Source location Response from HM Prison & Probation Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue a learning bulletin reminding staff to identify and refer prisoners who appear to be self-neglecting for assessment and support.
Verbatim wording from the response “The findings from your report will be used to inform the activities needed to deliver this commitment. In the interim, HMPPS will issue a learning bulletin to remind staff of the existing requirements to identify and refer prisoners for assessment who appear to be self-neglecting, and describe the actions that staff can take to support prisoners in such circumstances.” Source location Response from HM Prison & Probation Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Create and publish local guidance for caring for prisoners at risk of self-neglect, in collaboration with healthcare.
Verbatim wording from the response “Locally, HMP Guys Marsh have recently introduced a Buddy (Peer Led Mentor) scheme to provide support for complex and vulnerable prisoners. There are currently seven Buddies in place, and the prison are working on increasing this number. You heard evidence during the inquest that the prison, are in the process of creating local guidance for caring for those at risk of self-neglect. I wish to assure you the prison is working in collaboration with healthcare to ensure this is published as soon as possible.” Source location Response from HM Prison & Probation Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate a weekly DPS assurance check requiring case notes for all prisoners, with daily entries for prisoners isolating, showing self-neglect signs or having social-care needs.
Verbatim wording from the response “All prison officers and staff receive an initial course of NOMIS training that includes the importance of record keeping. While staff do not undertake refresher training on the use of NOMIS, staff have received guidance on the new Digital Prison Service (DPS) reporting tool which allows easier access to record keeping. In addition to this, the safety team at HMP Guys Marsh have introduced an assurance check that ensures all prisoners have a case note recorded on DPS weekly. Those prisoners who have been identified as isolating, showing signs of self-neglect, or have identified social care needs must have a daily entry inputted.” Source location Response from HM Prison & Probation Service
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing DPS guidance and weekly assurance checks are relied on instead of refresher NOMIS training for prison staff.
Verbatim wording from the response “All prison officers and staff receive an initial course of NOMIS training that includes the importance of record keeping. While staff do not undertake refresher training on the use of NOMIS, staff have received guidance on the new Digital Prison Service (DPS) reporting tool which allows easier access to record keeping. In addition to this, the safety team at HMP Guys Marsh have introduced an assurance check that ensures all prisoners have a case note recorded on DPS weekly. Those prisoners who have been identified as isolating, showing signs of self-neglect, or have identified social care needs must have a daily entry inputted.” Source location Response from HM Prison & Probation Service
Open published response
30 Jan 2023 Mr Nathan Forrester · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 5 Unavailability of airways in emergency bags View source Inadequate handover during resuscitation emergencies View source Failure of nurses to provide effective resuscitation View source Lack of nurse training in insertion of iGel or oropharyngeal airways View source Lack of prison officer training for assessment, removal and immediate CPR of prisoners on top bunks 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
Mr Nathan Forrester · 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
Mr Nathan Forrester died in a shared prison cell after consuming illicit drugs, and the jury concluded that he died of a drug-related death. Concerns included delays and insufficient training in removing an unresponsive prisoner from a top bunk for CPR, and gaps in nurses’ CPR, airway-management and handover training in detention settings.
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 airways in emergency bags
Wider context from the report “2. Training of nurses in CPR (NHS England)
Nurses attending the Code Blue had no training insertion of an IGel or oropharyngeal tube, nor was an airway available in the emergency bags . Paramedics reported that resuscitation being provided by nurses was ineffective (too low and too fast) and that they had an inadequate handover. These deficiencies have been addressed locally and all nurses in Oxleas NHS Trust are trained annually to ILS level and airways are available. The concern is that this standard of training of nurses working in detention settings nationally may not be universal.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 handover during resuscitation emergencies
Wider context from the report “2. Training of nurses in CPR (NHS England)
Nurses attending the Code Blue had no training insertion of an IGel or oropharyngeal tube, nor was an airway available in the emergency bags. Paramedics reported that resuscitation being provided by nurses was ineffective (too low and too fast) and that they had an inadequate handover . These deficiencies have been addressed locally and all nurses in Oxleas NHS Trust are trained annually to ILS level and airways are available. The concern is that this standard of training of nurses working in detention settings nationally may not be universal.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 nurses to provide effective resuscitation
Wider context from the report “2. Training of nurses in CPR (NHS England)
Nurses attending the Code Blue had no training insertion of an IGel or oropharyngeal tube, nor was an airway available in the emergency bags. Paramedics reported that resuscitation being provided by nurses was ineffective (too low and too fast) and that they had an inadequate handover. These deficiencies have been addressed locally and all nurses in Oxleas NHS Trust are trained annually to ILS level and airways are available. The concern is that this standard of training of nurses working in detention settings nationally may not be universal.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 nurse training in insertion of iGel or oropharyngeal airways
Wider context from the report “2. Training of nurses in CPR (NHS England)
Nurses attending the Code Blue had no training insertion of an IGel or oropharyngeal tube , nor was an airway available in the emergency bags. Paramedics reported that resuscitation being provided by nurses was ineffective (too low and too fast) and that they had an inadequate handover. These deficiencies have been addressed locally and all nurses in Oxleas NHS Trust are trained annually to ILS level and airways are available. The concern is that this standard of training of nurses working in detention settings nationally may not be universal.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 officer training for assessment, removal and immediate CPR of prisoners on top bunks
Wider context from the report “1. Deaths on top bunks (HMPPS)
The first prison officer to arrive and find Mr Forrester unresponsive to voice, blue and cold, decided she was too small to be able to get him off his top bunk, even with a colleague, and left the cell. A second officer, having confirmed no pulse or response to pain, stated that there was no specific training on how to manage an arrest and CPR of a person on a top bunk . He tried unsuccessfully to bring him down. A third officer attending did not attempt to do so. After some delay, nurses brought him down to floor level when they arrived. The Head of Safer Custody has asked the local health service provider to advise how prison officers should be trained to manage assessment, removal and immediate CPR of a prisoner on a top bunk. The concern is that this training gap may exist in other establishments.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide initial first-aid training covering movement of unresponsive prisoners to a hard, flat surface before CPR.
Verbatim wording from the response “I can confirm that all new prison officers receive first aid training as part of their initial prison officer training. The training covers the requirement to move individuals to a hard, flat surface before commencing CPR, and as such staff are aware that anyone found unresponsive on a top bunk bed would need to be brought to the floor prior to commencing CPR. The Learning and Development team, responsible for the management and delivery of training for HMPPS staff, also provide training in manual handling and movement of prisoners to ensure that our staff are well equipped with the skills to move a prisoner in order to enable CPR and emergency first aid to commence.” Source location Response from HM Prison and Probation Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Make manual-handling training available digitally through initial induction and an e-learning platform accessible to all staff.
Verbatim wording from the response “Manual handling training has recently been updated to a digital format and all new prison officers complete this during their initial training induction. In addition, there is e-learning available to all staff on MyLearning which is the digital learning platform used by HMPPS.” 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 Provide manual-handling and prisoner-movement training to equip staff to move prisoners for CPR and emergency first aid.
Verbatim wording from the response “I can confirm that all new prison officers receive first aid training as part of their initial prison officer training. The training covers the requirement to move individuals to a hard, flat surface before commencing CPR, and as such staff are aware that anyone found unresponsive on a top bunk bed would need to be brought to the floor prior to commencing CPR. The Learning and Development team, responsible for the management and delivery of training for HMPPS staff, also provide training in manual handling and movement of prisoners to ensure that our staff are well equipped with the skills to move a prisoner in order to enable CPR and emergency first aid to commence.” 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 first aid and manual handling training is considered sufficient for officers to move prisoners and commence CPR.
Verbatim wording from the response “I can confirm that all new prison officers receive first aid training as part of their initial prison officer training. The training covers the requirement to move individuals to a hard, flat surface before commencing CPR, and as such staff are aware that anyone found unresponsive on a top bunk bed would need to be brought to the floor prior to commencing CPR. The Learning and Development team, responsible for the management and delivery of training for HMPPS staff, also provide training in manual handling and movement of prisoners to ensure that our staff are well equipped with the skills to move a prisoner in order to enable CPR and emergency first aid to commence.” Source location Response from HM Prison and Probation Service
Open published response
17 Jan 2023 John Allen Martin HENDERSON · Prevention of Future Deaths report Mid Kent and Medway
View report summary
Concerns raised 3 Failure to provide closer monitoring for prisoners with seizure activity View source Failure to conduct start-of-day prisoner welfare checks View source Lack of a clear process for consent-based disclosure of prisoners' medical information to front line officers 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
John Allen Martin HENDERSON · 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
John Allen Martin Henderson was found dead in his bunk at HMP Rochester on 27 May 2021. The inquest recorded natural causes, namely ischaemic heart disease, following a fatal haemorrhage into the wall of the left circumflex artery. Concerns included delayed medical investigations, the absence of a welfare check at the start of the day, and a lack of a clear process for sharing relevant medical information with front-line prison 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 to provide closer monitoring for prisoners with seizure activity
Wider context from the report “During the course of evidence, I also established that John was not being monitored any more
closely than other prisoners due to his seizure activity . That was confirmed by ████████
████████ in the course of their evidence. They indicated to me that sometimes they
will be asked to monitor prisoners more closely but this had not been applied to John .
Likewise, nobody had checked the welfare of John at the start of the day on 27 May 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 conduct start-of-day prisoner welfare checks
Wider context from the report “During the course of evidence, I also established that John was not being monitored any more
closely than other prisoners due to his seizure activity. That was confirmed by ████████
████████ in the course of their evidence. They indicated to me that sometimes they
will be asked to monitor prisoners more closely but this had not been applied to John.
Likewise, nobody had checked the welfare of John at the start of the day on 27 May 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 Lack of a clear process for consent-based disclosure of prisoners' medical information to front line officers
Wider context from the report “I asked additional questions of witnesses and asked to have sight of policies and procedures
in respect of information sharing protocols and procedures in respect of prisoners with chronic
conditions, (be is seizure activity, diabetes, cardiac issues). My concern being that there did
not appear to be a clear process for prisoners to consent to disclosure of medical information
to front line officers so that they could be made aware that a particular prisoner may be prone
to sudden or unexpected medical episodes.
My concern was that a prisoner could have a sudden (but perhaps predictable) acute medical
episode and front line prison staff may not be made aware of what was causing the issue or
how to respond thereto .
” Open source report
5 Jan 2023 Floyd Everton CARRUTHERS · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 2 Lack of national and local training for effective implementation of adult safeguarding policy View source Inadequate safeguarding escalation process for non-violent, non-self-harm-related injurious activity View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Floyd Everton CARRUTHERS · 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
Floyd Everton Carruthers was detained at HMP Birmingham and died in hospital on 14 June 2021 after developing infective endocarditis, cardiac tamponade, and multi-organ failure. The report raises concerns about inadequate safeguarding training and escalation processes, insufficient record keeping and handover, and failures to refer him to healthcare despite missed meals and not leaving his cell. The jury concluded that his death was contributed to by neglect.
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 national and local training for effective implementation of adult safeguarding policy
Wider context from the report “1. At the time Mr Carruthers resided in HMP Birmingham, National Offender Management Service, Adult Safeguarding in Prison Policy, PSI 16/2015 dated 31/3/19 was in force. This policy states at paragraph 1.10 (under the heading "Mandatory Actions") "Governors must have systems in place to protect adult prisoners from abuse and neglect". At paragraph 2.4 the policy states "Neglect also includes self-neglect, which covers a wide range of behaviour such as neglecting to care for one's personal hygiene, health or surroundings and behaviour such as hoarding". My concern is that while there is a national policy dealing with safeguarding, to include instances of self-neglect, no adequate training exists at either national or local level to ensure the effective implementation of that policy .
2. While evidence was heard from prison staff detailing a number of potential escalation routes for what might be termed 'social isolation' (an instance, as with Mr Carruthers, where they had not left their cell for a period of days but had not been observed to have were self isolating), notably ACCT and CISP, none of the officers appeared aware of a corresponding process for raising safeguarding issues. The known escalation routes (ACCT and CISP) are more focussed on violence and self-harm, leaving at the very least a conceptual gap in how best to deal with injurious activity which is neither violent nor directly/obviously contributory to self-harm, such as self-neglect. My concern is that the existing safeguarding escalation process is either inadequate, inappropriately trained or both
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 safeguarding escalation process for non-violent, non-self-harm-related injurious activity
Wider context from the report “2. While evidence was heard from prison staff detailing a number of potential escalation routes for what might be termed 'social isolation' (an instance, as with Mr Carruthers, where they had not left their cell for a period of days but had not been observed to have were self isolating), notably ACCT and CISP, none of the officers appeared aware of a corresponding process for raising safeguarding issues . The known escalation routes (ACCT and CISP) are more focussed on violence and self-harm, leaving at the very least a conceptual gap in how best to deal with injurious activity which is neither violent nor directly/obviously contributory to self-harm, such as self-neglect . My concern is that the existing safeguarding escalation process is either inadequate, inappropriately trained or both
” 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 Instruct suicide and self-harm prevention trainers to place greater emphasis on self-neglect.
Verbatim wording from the response “In addition to this, safeguarding is now a standing item at the weekly Governing Governor’s briefing at HMP Birmingham. The establishment’s suicide and self-harm prevention trainers have been instructed to place more emphasis on issues relating to self-neglect, and from December 2023 a HMPPS training programme focused specifically on safeguarding will become available.” Source location Response from HM Prison and Probation Services
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 staff notice clarifying safeguarding responsibilities and escalation routes for prisoners experiencing self-neglect.
Verbatim wording from the response “On 9 March 2023, the Governor at HMP Birmingham issued a notice to staff on the subject of safeguarding, stating very clearly that when a prisoner is found to be neglecting their own welfare it is the responsibility of staff to ensure that appropriate action is taken to ensure that their needs are met using relevant processes and to provide ongoing support. Staff are reminded to report such instances to the prison safeguarding lead (the Head of Safer Custody) who will consider the suitability of making a referral for a social care assessment.” Source location Response from HM Prison and Probation Services
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 learning bulletin reminding staff to identify and refer prisoners who appear to be self-neglecting and support them appropriately.
Verbatim wording from the response “In the meantime, HMPPS will issue a learning bulletin that will remind staff of the existing requirements to identify and refer for assessment prisoners who appear to be self-neglecting, and describe the actions that staff can take to support prisoners in such circumstances.” Source location Response from HM Prison and Probation Services
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 a safeguarding-focused HMPPS training programme available to staff from December 2023.
Verbatim wording from the response “In addition to this, safeguarding is now a standing item at the weekly Governing Governor’s briefing at HMP Birmingham. The establishment’s suicide and self-harm prevention trainers have been instructed to place more emphasis on issues relating to self-neglect, and from December 2023 a HMPPS training programme focused specifically on safeguarding will become available.” Source location Response from HM Prison and Probation Services
Open published response
Concerns raised 6 Failure to undertake medical and mental health assessments on SACU View source Failure to allocate SACU tasks through a reliable planned process View source Sparse NOMIS record keeping for SACU View source Delays in obtaining backup for emergencies on SACU during patrol state View source Insufficient staffing for safe operation of the three-man unlock on SACU View source Under-utilisation of the daily log as a multidisciplinary tool 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
Michael Raymond SMITH · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Michael Raymond SMITH entered HMP Durham on 10 July 2020, was transferred to SACU after being found to have packages concealed internally, and was discovered self-suspended on 11 July; he died in hospital on 13 July 2020. The principal concerns included the absence of medical and mental health assessments, inadequate staffing while he was subject to three-man unlock, delays in responding to the suspension, and weaknesses in SACU record keeping and multidisciplinary oversight.
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 undertake medical and mental health assessments on SACU
Wider context from the report “Between his arrival in SACU at 18.37 on 10 July 2020 and his being discovered self suspended with a ligature at 17.45 on 11 July 2020 there, Michael was subject to a 3 man unlock.
On the morning of 11 July, a Saturday, there were 3 officers on duty on SACU. This did permit his cell to be unlocked for a meal to be delivered and for a cursory one and a half minute conversation with a nurse that fell short, on her evidence, of an actual medical examination.
On the afternoon of 11 July there were only one or (briefly) two officers on SACU duty per the staff duty log, albeit, as CCTV footage shows, more officers did attend intermittently for specific tasks. The SACU staff duty log shows only one officer on duty for the whole afternoon to 17.00. In any event medical assessments of Michael were not undertaken at any stage while he was on SACU , the reason being given that he was on three man unlock. It appears that there were never sufficient staff available for a dedicated medical assessment to be undertaken. This notwithstanding that evidence from prison officers and a nurse was that during the course of the afternoon Michael`s presentation had become “angrier” and “bizarre”. In fact, it is now known, he had been ingesting toxic amounts ████████, an unlicensed drug, he had secreted into the prison (his being detected at reception as plugged lead him to SACU). ████████ is a highly potent ████████ which effects judgement and lowers inhibitions. The jury subsequently concluded that the absence of medical, and mental health, assessments , and the use of the ████████ (which was never diagnosed), contributed to the Michael`s death.
From 17.00, when patrol state commenced, there was clearly only one officer on duty and present. When she discovered Michael self suspended that officer made a perfectly defensible dynamic assessment, electing not to enter the cell unsupported. She made ready to enter for when back up arrived. In the event, partly because there was another discipline incident unfolding on a different wing, this took 2-3 minutes. There were only 16 prison officers available while on patrol state across the entire prison, and they were already at full stretch, and probably beyond it (the Tactical Resources Unit from Doncaster were en route).
The evidence was that without knowing precisely when Michael self-suspended any such delay could not be held, on a balance of probabilities, to have entered the chain of causation death. However, the fact remains that there was a delay consequent to Michael being on a three man unlock but there being only a single officer available on SACU while in patrol state. It is reasonable to conjecture that this could have made the difference between life and death in this case, and the repetition of these circumstances could well do so in future.
In your response dated 15 November 2021 to the Regulation 28 report of HM Assistant Coroner James Thompson of 21 September 2021 following the Inquest into the death of Charlie Brian Todd at HMP Durham, you wrote, amongst other things:
“There is clear management oversight of the SACU”.
This is not what the evidence in the instance case showed. Rather, what it made clear was that:
1) the SACU staff log plus CCTV further demonstrated that officers, including officers not posted to SACU, but covering for a shift, were required to allocate various task between themselves on an ad-hoc basis” was an ongoing problem, and this appears to be still ongoing;
2) NOMIS record keeping was unhelpfully sparse (“you would expect more” was the evidence of SACU manager);
3) the daily log was under-utilised as a multi-disciplinary tool, and this appears to be ongoing.
You also stated:
“I am confident that the staffing levels and supervisory arrangements in place are sufficient to deliver all of the SACU`s regime”.
This, too, is clearly not the case. Staffing levels remain the same. Safeguarding of prisoners is comprised as a consequence. With a three man unlock imposed, there should be three officers available at all times to ensure safety. Staffing levels at HMP Durham should be increased.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 allocate SACU tasks through a reliable planned process
Wider context from the report “Between his arrival in SACU at 18.37 on 10 July 2020 and his being discovered self suspended with a ligature at 17.45 on 11 July 2020 there, Michael was subject to a 3 man unlock.
On the morning of 11 July, a Saturday, there were 3 officers on duty on SACU. This did permit his cell to be unlocked for a meal to be delivered and for a cursory one and a half minute conversation with a nurse that fell short, on her evidence, of an actual medical examination.
On the afternoon of 11 July there were only one or (briefly) two officers on SACU duty per the staff duty log, albeit, as CCTV footage shows, more officers did attend intermittently for specific tasks. The SACU staff duty log shows only one officer on duty for the whole afternoon to 17.00. In any event medical assessments of Michael were not undertaken at any stage while he was on SACU, the reason being given that he was on three man unlock. It appears that there were never sufficient staff available for a dedicated medical assessment to be undertaken. This notwithstanding that evidence from prison officers and a nurse was that during the course of the afternoon Michael`s presentation had become “angrier” and “bizarre”. In fact, it is now known, he had been ingesting toxic amounts ████████, an unlicensed drug, he had secreted into the prison (his being detected at reception as plugged lead him to SACU). ████████ is a highly potent ████████ which effects judgement and lowers inhibitions. The jury subsequently concluded that the absence of medical, and mental health, assessments, and the use of the ████████ (which was never diagnosed), contributed to the Michael`s death.
From 17.00, when patrol state commenced, there was clearly only one officer on duty and present. When she discovered Michael self suspended that officer made a perfectly defensible dynamic assessment, electing not to enter the cell unsupported. She made ready to enter for when back up arrived. In the event, partly because there was another discipline incident unfolding on a different wing, this took 2-3 minutes. There were only 16 prison officers available while on patrol state across the entire prison, and they were already at full stretch, and probably beyond it (the Tactical Resources Unit from Doncaster were en route).
The evidence was that without knowing precisely when Michael self-suspended any such delay could not be held, on a balance of probabilities, to have entered the chain of causation death. However, the fact remains that there was a delay consequent to Michael being on a three man unlock but there being only a single officer available on SACU while in patrol state. It is reasonable to conjecture that this could have made the difference between life and death in this case, and the repetition of these circumstances could well do so in future.
In your response dated 15 November 2021 to the Regulation 28 report of HM Assistant Coroner James Thompson of 21 September 2021 following the Inquest into the death of Charlie Brian Todd at HMP Durham, you wrote, amongst other things:
“There is clear management oversight of the SACU”.
This is not what the evidence in the instance case showed. Rather, what it made clear was that:
1) the SACU staff log plus CCTV further demonstrated that officers, including officers not posted to SACU, but covering for a shift, were required to allocate various task between themselves on an ad-hoc basis” was an ongoing problem, and this appears to be still ongoing ;
2) NOMIS record keeping was unhelpfully sparse (“you would expect more” was the evidence of SACU manager);
3) the daily log was under-utilised as a multi-disciplinary tool, and this appears to be ongoing.
You also stated:
“I am confident that the staffing levels and supervisory arrangements in place are sufficient to deliver all of the SACU`s regime”.
This, too, is clearly not the case. Staffing levels remain the same. Safeguarding of prisoners is comprised as a consequence. With a three man unlock imposed, there should be three officers available at all times to ensure safety. Staffing levels at HMP Durham should be increased.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Sparse NOMIS record keeping for SACU
Wider context from the report “Between his arrival in SACU at 18.37 on 10 July 2020 and his being discovered self suspended with a ligature at 17.45 on 11 July 2020 there, Michael was subject to a 3 man unlock.
On the morning of 11 July, a Saturday, there were 3 officers on duty on SACU. This did permit his cell to be unlocked for a meal to be delivered and for a cursory one and a half minute conversation with a nurse that fell short, on her evidence, of an actual medical examination.
On the afternoon of 11 July there were only one or (briefly) two officers on SACU duty per the staff duty log, albeit, as CCTV footage shows, more officers did attend intermittently for specific tasks. The SACU staff duty log shows only one officer on duty for the whole afternoon to 17.00. In any event medical assessments of Michael were not undertaken at any stage while he was on SACU, the reason being given that he was on three man unlock. It appears that there were never sufficient staff available for a dedicated medical assessment to be undertaken. This notwithstanding that evidence from prison officers and a nurse was that during the course of the afternoon Michael`s presentation had become “angrier” and “bizarre”. In fact, it is now known, he had been ingesting toxic amounts ████████, an unlicensed drug, he had secreted into the prison (his being detected at reception as plugged lead him to SACU). ████████ is a highly potent ████████ which effects judgement and lowers inhibitions. The jury subsequently concluded that the absence of medical, and mental health, assessments, and the use of the ████████ (which was never diagnosed), contributed to the Michael`s death.
From 17.00, when patrol state commenced, there was clearly only one officer on duty and present. When she discovered Michael self suspended that officer made a perfectly defensible dynamic assessment, electing not to enter the cell unsupported. She made ready to enter for when back up arrived. In the event, partly because there was another discipline incident unfolding on a different wing, this took 2-3 minutes. There were only 16 prison officers available while on patrol state across the entire prison, and they were already at full stretch, and probably beyond it (the Tactical Resources Unit from Doncaster were en route).
The evidence was that without knowing precisely when Michael self-suspended any such delay could not be held, on a balance of probabilities, to have entered the chain of causation death. However, the fact remains that there was a delay consequent to Michael being on a three man unlock but there being only a single officer available on SACU while in patrol state. It is reasonable to conjecture that this could have made the difference between life and death in this case, and the repetition of these circumstances could well do so in future.
In your response dated 15 November 2021 to the Regulation 28 report of HM Assistant Coroner James Thompson of 21 September 2021 following the Inquest into the death of Charlie Brian Todd at HMP Durham, you wrote, amongst other things:
“There is clear management oversight of the SACU”.
This is not what the evidence in the instance case showed. Rather, what it made clear was that:
1) the SACU staff log plus CCTV further demonstrated that officers, including officers not posted to SACU, but covering for a shift, were required to allocate various task between themselves on an ad-hoc basis” was an ongoing problem, and this appears to be still ongoing;
2) NOMIS record keeping was unhelpfully sparse (“you would expect more” was the evidence of SACU manager) ;
3) the daily log was under-utilised as a multi-disciplinary tool, and this appears to be ongoing.
You also stated:
“I am confident that the staffing levels and supervisory arrangements in place are sufficient to deliver all of the SACU`s regime”.
This, too, is clearly not the case. Staffing levels remain the same. Safeguarding of prisoners is comprised as a consequence. With a three man unlock imposed, there should be three officers available at all times to ensure safety. Staffing levels at HMP Durham should be increased.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 obtaining backup for emergencies on SACU during patrol state
Wider context from the report “Between his arrival in SACU at 18.37 on 10 July 2020 and his being discovered self suspended with a ligature at 17.45 on 11 July 2020 there, Michael was subject to a 3 man unlock.
On the morning of 11 July, a Saturday, there were 3 officers on duty on SACU. This did permit his cell to be unlocked for a meal to be delivered and for a cursory one and a half minute conversation with a nurse that fell short, on her evidence, of an actual medical examination.
On the afternoon of 11 July there were only one or (briefly) two officers on SACU duty per the staff duty log, albeit, as CCTV footage shows, more officers did attend intermittently for specific tasks. The SACU staff duty log shows only one officer on duty for the whole afternoon to 17.00. In any event medical assessments of Michael were not undertaken at any stage while he was on SACU, the reason being given that he was on three man unlock. It appears that there were never sufficient staff available for a dedicated medical assessment to be undertaken. This notwithstanding that evidence from prison officers and a nurse was that during the course of the afternoon Michael`s presentation had become “angrier” and “bizarre”. In fact, it is now known, he had been ingesting toxic amounts ████████, an unlicensed drug, he had secreted into the prison (his being detected at reception as plugged lead him to SACU). ████████ is a highly potent ████████ which effects judgement and lowers inhibitions. The jury subsequently concluded that the absence of medical, and mental health, assessments, and the use of the ████████ (which was never diagnosed), contributed to the Michael`s death.
From 17.00, when patrol state commenced, there was clearly only one officer on duty and present. When she discovered Michael self suspended that officer made a perfectly defensible dynamic assessment, electing not to enter the cell unsupported. She made ready to enter for when back up arrived. In the event, partly because there was another discipline incident unfolding on a different wing, this took 2-3 minutes. There were only 16 prison officers available while on patrol state across the entire prison, and they were already at full stretch, and probably beyond it (the Tactical Resources Unit from Doncaster were en route).
The evidence was that without knowing precisely when Michael self-suspended any such delay could not be held, on a balance of probabilities, to have entered the chain of causation death. However, the fact remains that there was a delay consequent to Michael being on a three man unlock but there being only a single officer available on SACU while in patrol state. It is reasonable to conjecture that this could have made the difference between life and death in this case, and the repetition of these circumstances could well do so in future.
In your response dated 15 November 2021 to the Regulation 28 report of HM Assistant Coroner James Thompson of 21 September 2021 following the Inquest into the death of Charlie Brian Todd at HMP Durham, you wrote, amongst other things:
“There is clear management oversight of the SACU”.
This is not what the evidence in the instance case showed. Rather, what it made clear was that:
1) the SACU staff log plus CCTV further demonstrated that officers, including officers not posted to SACU, but covering for a shift, were required to allocate various task between themselves on an ad-hoc basis” was an ongoing problem, and this appears to be still ongoing;
2) NOMIS record keeping was unhelpfully sparse (“you would expect more” was the evidence of SACU manager);
3) the daily log was under-utilised as a multi-disciplinary tool, and this appears to be ongoing.
You also stated:
“I am confident that the staffing levels and supervisory arrangements in place are sufficient to deliver all of the SACU`s regime”.
This, too, is clearly not the case. Staffing levels remain the same. Safeguarding of prisoners is comprised as a consequence. With a three man unlock imposed, there should be three officers available at all times to ensure safety. Staffing levels at HMP Durham should be increased.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Insufficient staffing for safe operation of the three-man unlock on SACU
Wider context from the report “Between his arrival in SACU at 18.37 on 10 July 2020 and his being discovered self suspended with a ligature at 17.45 on 11 July 2020 there, Michael was subject to a 3 man unlock.
On the morning of 11 July, a Saturday, there were 3 officers on duty on SACU. This did permit his cell to be unlocked for a meal to be delivered and for a cursory one and a half minute conversation with a nurse that fell short, on her evidence, of an actual medical examination.
On the afternoon of 11 July there were only one or (briefly) two officers on SACU duty per the staff duty log , albeit, as CCTV footage shows, more officers did attend intermittently for specific tasks. The SACU staff duty log shows only one officer on duty for the whole afternoon to 17.00. In any event medical assessments of Michael were not undertaken at any stage while he was on SACU, the reason being given that he was on three man unlock. It appears that there were never sufficient staff available for a dedicated medical assessment to be undertaken. This notwithstanding that evidence from prison officers and a nurse was that during the course of the afternoon Michael`s presentation had become “angrier” and “bizarre”. In fact, it is now known, he had been ingesting toxic amounts ████████, an unlicensed drug, he had secreted into the prison (his being detected at reception as plugged lead him to SACU). ████████ is a highly potent ████████ which effects judgement and lowers inhibitions. The jury subsequently concluded that the absence of medical, and mental health, assessments, and the use of the ████████ (which was never diagnosed), contributed to the Michael`s death.
From 17.00, when patrol state commenced, there was clearly only one officer on duty and present. When she discovered Michael self suspended that officer made a perfectly defensible dynamic assessment, electing not to enter the cell unsupported. She made ready to enter for when back up arrived. In the event, partly because there was another discipline incident unfolding on a different wing, this took 2-3 minutes. There were only 16 prison officers available while on patrol state across the entire prison, and they were already at full stretch, and probably beyond it (the Tactical Resources Unit from Doncaster were en route).
The evidence was that without knowing precisely when Michael self-suspended any such delay could not be held, on a balance of probabilities, to have entered the chain of causation death. However, the fact remains that there was a delay consequent to Michael being on a three man unlock but there being only a single officer available on SACU while in patrol state. It is reasonable to conjecture that this could have made the difference between life and death in this case, and the repetition of these circumstances could well do so in future.
In your response dated 15 November 2021 to the Regulation 28 report of HM Assistant Coroner James Thompson of 21 September 2021 following the Inquest into the death of Charlie Brian Todd at HMP Durham, you wrote, amongst other things:
“There is clear management oversight of the SACU”.
This is not what the evidence in the instance case showed. Rather, what it made clear was that:
1) the SACU staff log plus CCTV further demonstrated that officers, including officers not posted to SACU, but covering for a shift, were required to allocate various task between themselves on an ad-hoc basis” was an ongoing problem, and this appears to be still ongoing;
2) NOMIS record keeping was unhelpfully sparse (“you would expect more” was the evidence of SACU manager);
3) the daily log was under-utilised as a multi-disciplinary tool, and this appears to be ongoing.
You also stated:
“I am confident that the staffing levels and supervisory arrangements in place are sufficient to deliver all of the SACU`s regime”.
This, too, is clearly not the case. Staffing levels remain the same. Safeguarding of prisoners is comprised as a consequence. With a three man unlock imposed, there should be three officers available at all times to ensure safety. Staffing levels at HMP Durham should be increased.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Under-utilisation of the daily log as a multidisciplinary tool
Wider context from the report “Between his arrival in SACU at 18.37 on 10 July 2020 and his being discovered self suspended with a ligature at 17.45 on 11 July 2020 there, Michael was subject to a 3 man unlock.
On the morning of 11 July, a Saturday, there were 3 officers on duty on SACU. This did permit his cell to be unlocked for a meal to be delivered and for a cursory one and a half minute conversation with a nurse that fell short, on her evidence, of an actual medical examination.
On the afternoon of 11 July there were only one or (briefly) two officers on SACU duty per the staff duty log, albeit, as CCTV footage shows, more officers did attend intermittently for specific tasks. The SACU staff duty log shows only one officer on duty for the whole afternoon to 17.00. In any event medical assessments of Michael were not undertaken at any stage while he was on SACU, the reason being given that he was on three man unlock. It appears that there were never sufficient staff available for a dedicated medical assessment to be undertaken. This notwithstanding that evidence from prison officers and a nurse was that during the course of the afternoon Michael`s presentation had become “angrier” and “bizarre”. In fact, it is now known, he had been ingesting toxic amounts ████████, an unlicensed drug, he had secreted into the prison (his being detected at reception as plugged lead him to SACU). ████████ is a highly potent ████████ which effects judgement and lowers inhibitions. The jury subsequently concluded that the absence of medical, and mental health, assessments, and the use of the ████████ (which was never diagnosed), contributed to the Michael`s death.
From 17.00, when patrol state commenced, there was clearly only one officer on duty and present. When she discovered Michael self suspended that officer made a perfectly defensible dynamic assessment, electing not to enter the cell unsupported. She made ready to enter for when back up arrived. In the event, partly because there was another discipline incident unfolding on a different wing, this took 2-3 minutes. There were only 16 prison officers available while on patrol state across the entire prison, and they were already at full stretch, and probably beyond it (the Tactical Resources Unit from Doncaster were en route).
The evidence was that without knowing precisely when Michael self-suspended any such delay could not be held, on a balance of probabilities, to have entered the chain of causation death. However, the fact remains that there was a delay consequent to Michael being on a three man unlock but there being only a single officer available on SACU while in patrol state. It is reasonable to conjecture that this could have made the difference between life and death in this case, and the repetition of these circumstances could well do so in future.
In your response dated 15 November 2021 to the Regulation 28 report of HM Assistant Coroner James Thompson of 21 September 2021 following the Inquest into the death of Charlie Brian Todd at HMP Durham, you wrote, amongst other things:
“There is clear management oversight of the SACU”.
This is not what the evidence in the instance case showed. Rather, what it made clear was that:
1) the SACU staff log plus CCTV further demonstrated that officers, including officers not posted to SACU, but covering for a shift, were required to allocate various task between themselves on an ad-hoc basis” was an ongoing problem, and this appears to be still ongoing;
2) NOMIS record keeping was unhelpfully sparse (“you would expect more” was the evidence of SACU manager);
3) the daily log was under-utilised as a multi-disciplinary tool, and this appears to be ongoing.
You also stated:
“I am confident that the staffing levels and supervisory arrangements in place are sufficient to deliver all of the SACU`s regime”.
This, too, is clearly not the case. Staffing levels remain the same. Safeguarding of prisoners is comprised as a consequence. With a three man unlock imposed, there should be three officers available at all times to ensure safety. Staffing levels at HMP Durham should be increased.
” 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 Base a full-time nurse within the SACU to provide flexible healthcare input, including medical assessments.
Verbatim wording from the response “As result of some early evaluations, a full time nurse is now based within the SACU, which has meant there can be a more flexible approach regarding healthcare input, including the arrangements for medical assessments.” 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 segregation weekly booklet consolidating recording sheets and documenting significant interactions for each prisoner.
Verbatim wording from the response “The running of the SACU is further subject to daily checks undertaken by the Orderly Officer and Duty Governor, and the Governor undertakes a weekly in-charge check. Since Mr Smith’s death a new segregation weekly booklet has been introduced which amalgamates all previous segregation recording sheets together in one place. Each prisoner has their own booklet, which means an individual’s records are more readily accessible to staff. The booklet also contains a section to record any comments regarding significant interactions to ensure full records are maintained.” Source location Response from HM Prison and Probation Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review contingency plans to incorporate incident learning and prompt consideration of regime levels and available resources during simultaneous incidents.
Verbatim wording from the response “Unfortunately we must accept that there will be occasions where staff may have to deal with several incidents at once and that these may be taking place in other areas of the prison. We also know that at the time of Mr Smith’s death, resources were being affected due to Durham being a Covid outbreak site. However, HMP Durham will review its contingency plans to incorporate the learning from this incident so that prompts are given to those responsible for managing protracted events to consider regime levels and available resources across the prison, to allow for the appropriate deployment of staff should other incidents occur at the same time.” 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 Provide additional SACU staffing resources above national benchmarking requirements.
Verbatim wording from the response “I note that you have referred to a Regulation 28 response relating to an earlier death at HMP Durham. I would like to clarify that this response was sent after Mr Smith’s death, which means the additional resources that were created by the Governor would not have been implemented prior to the death of Mr Smith. However, I can assure you these additional measures do remain in place at the present time which means that the staffing levels within the SACU at Durham are currently above those required by national benchmarking, the tool by which staffing levels are measured. I would also reiterate that the day-to-day running of the unit is overseen by a dedicated Custodial Manager (CM), responsible for the allocation of tasks and performance management of the officers working there.” Source location Response from HM Prison and Probation Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct a SACU pilot evaluating operational processes and health support to inform a safe, integrated workforce model.
Verbatim wording from the response “It may also be helpful for me to explain that where prisoners are subject to a three person unlock and staff are not readily available to facilitate this, then additional staff can be drawn from across the prison to assist. I acknowledge that at the time did not happen when Mr Smith required a medical assessment and accept staff did not take the necessary actions to ensure Mr Smith could be seen by a medical practitioner. However, the Governor is confident that where this situation arises in the future the resources are in place to respond effectively. A SACU pilot, which is looking at both operational processes within the SACU and the health support provided, is due to conclude in June 2023. This will assist in developing a new workforce model to support the delivery of a safe, integrated holistic approach to the care and management of those residing and working in segregation units.” 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 arrangements allow additional prison staff to assist with three-person unlocks, and resources are considered sufficient to respond effectively in future.
Verbatim wording from the response “It may also be helpful for me to explain that where prisoners are subject to a three person unlock and staff are not readily available to facilitate this, then additional staff can be drawn from across the prison to assist. I acknowledge that at the time did not happen when Mr Smith required a medical assessment and accept staff did not take the necessary actions to ensure Mr Smith could be seen by a medical practitioner. However, the Governor is confident that where this situation arises in the future the resources are in place to respond effectively. A SACU pilot, which is looking at both operational processes within the SACU and the health support provided, is due to conclude in June 2023. This will assist in developing a new workforce model to support the delivery of a safe, integrated holistic approach to the care and management of those residing and working in segregation units.” 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 Not entering the cell alone followed the correct procedure and was not criticised, despite the delayed arrival of assistance.
Verbatim wording from the response “You rightly point out that during patrol/night state, when prisoners would be locked behind their door, one officer is allocated to the SACU. However where an emergency response is required staff must undertake a dynamic risk assessment before entering a cell alone. This is the position throughout the prison during this time and would be the practice whether the person is subject to a three person unlock or not, although that information is likely to form part of the risk assessment. I do note that the decision not to enter the cell alone was not criticised and the correct procedure was followed. As you will be aware there was an unusual combination of circumstances ongoing within other parts of the prison at the time which meant the arrival of assistance was slightly delayed.” 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 Current SACU staffing exceeds national benchmarks and existing management arrangements are considered sufficient, so staffing increases are not indicated.
Verbatim wording from the response “I note that you have referred to a Regulation 28 response relating to an earlier death at HMP Durham. I would like to clarify that this response was sent after Mr Smith’s death, which means the additional resources that were created by the Governor would not have been implemented prior to the death of Mr Smith. However, I can assure you these additional measures do remain in place at the present time which means that the staffing levels within the SACU at Durham are currently above those required by national benchmarking, the tool by which staffing levels are measured. I would also reiterate that the day-to-day running of the unit is overseen by a dedicated Custodial Manager (CM), responsible for the allocation of tasks and performance management of the officers working there.” Source location Response from HM Prison and Probation Service
Open published response
24 Oct 2022 Bradleigh Trevor Barnes · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 2 Lack of national guidance for healthcare staff on the use of force in prison View source Absence of a local operating policy on the use of force between prison and healthcare services View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Bradleigh Trevor Barnes · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Bradleigh Trevor Barnes was found suspended by a ligature in his cell at HMP YOI Portland on 28 December 2019. The inquest concluded that the death was suicide. Concerns included a lack of national NHS guidance for healthcare staff on the use of force in prison and the absence of a local operating policy between the prison and healthcare provider at HMP YOI Portland.
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 national guidance for healthcare staff on the use of force in prison
Wider context from the report “i. There is a lack of national guidance to healthcare staff on the use of force in prison and I request consideration is given by NHS England to providing such national 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 Absence of a local operating policy on the use of force between prison and healthcare services
Wider context from the report “ii. There is no local operating policy on the use of force at HMP YOI Portland between the healthcare and the prison and I request that the Governor of HMP YOI Portland and the Chief Executive of Oxleas consider putting a local instruction policy in place.
” 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 Review and update the national use-of-force policy with healthcare colleagues engaged in the process.
Verbatim wording from the response “I am aware that NHS England are providing a separate response relating to issuing national Use of Force guidance for healthcare staff so I will not comment on this further but I wish to assure you that we continue striving to improve joined up working between prison and healthcare staff. The national use of force policy is currently being reviewed and updated, and healthcare colleagues are engaged as part of this process. I fully appreciate the important role that healthcare play in ensuring the safety of all prisoners and staff.” Source location Response from HM Prison & Probation Service (1)
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 Produce a memorandum of understanding defining healthcare roles during planned and unplanned use-of-force incidents and required post-incident actions.
Verbatim wording from the response “Following evidence heard at the inquest you have raised a concern that there was no local operating policy on the use of force between the prison and the healthcare provider. There is a new healthcare provider at the prison, Oxleas NHS Foundation Trust – Offender Healthcare Services. When healthcare providers are commissioned, part of the contract refers to the fact that they must adopt HMPPS policies and be guided by them. The contract began on 1 December 2022 and a memorandum of understanding (MOU) has been produced by the Governor of HMP Portland and the Service Director of Oxleas NHS Foundation Trust, setting out the role of healthcare during planned and unplanned use of force incidents as well as post incident actions to be followed to ensure the wellbeing of prisoners and staff.” Source location Response from HM Prison & Probation Service (1)
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 policies and the local memorandum of understanding address healthcare roles during planned and unplanned use of force incidents.
Verbatim wording from the response “Following evidence heard at the inquest you have raised a concern that there was no local operating policy on the use of force between the prison and the healthcare provider. There is a new healthcare provider at the prison, Oxleas NHS Foundation Trust – Offender Healthcare Services. When healthcare providers are commissioned, part of the contract refers to the fact that they must adopt HMPPS policies and be guided by them. The contract began on 1 December 2022 and a memorandum of understanding (MOU) has been produced by the Governor of HMP Portland and the Service Director of Oxleas NHS Foundation Trust, setting out the role of healthcare during planned and unplanned use of force incidents as well as post incident actions to be followed to ensure the wellbeing of prisoners and staff.” Source location Response from HM Prison & Probation Service (1)
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 NHS England is responsible for responding to national Use of Force guidance for healthcare staff.
Verbatim wording from the response “I am aware that NHS England are providing a separate response relating to issuing national Use of Force guidance for healthcare staff so I will not comment on this further but I wish to assure you that we continue striving to improve joined up working between prison and healthcare staff. The national use of force policy is currently being reviewed and updated, and healthcare colleagues are engaged as part of this process. I fully appreciate the important role that healthcare play in ensuring the safety of all prisoners and staff.” Source location Response from HM Prison & Probation Service (1)
Open published response
19 Jul 2022 Ezra Mathew TAMIEM · Prevention of Future Deaths report Bedfordshire and Luton
View report summary
Concerns raised 1 Failure to design out injury and ligature points from prison cells 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
Ezra Mathew TAMIEM · 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
Ezra Mathew Tamiem was detained at HMP Bedford and held in the healthcare wing because of concerns about his mental state and suicide risk. He was found hanging in his cell on 15 July 2020 and was confirmed deceased by paramedics. The concerns included a ligature point in the cell and a serious failure of the required observation procedure, with only two of five recorded observations performed.
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 design out injury and ligature points from prison cells
Wider context from the report “Mr Tamiem was housed in a cell on the healthcare wing. ████████ Head
of Safety at HMP Bedford told the court that was for both security ████████
████████ gave evidence that this device was in operation throughout the prison except in the refurbished cells and except in the “safer cell” . The safer cell did not have this ligature point. Safer cells are cells with injury and ligature points designed out.
████████ hanged himself
and died as a result.
████████ told the court that there were no plans to remedy this and so the risk remains.
” Open source report
Concerns raised 1 Lack of effective communication between healthcare personnel at medical emergencies and prison or ambulance control 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
Thomas Mark Anthony Moffett · 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
Thomas Mark Anthony Moffett had probably suffered from diarrhoea and vomiting for up to three weeks before dying from natural causes following a cardiac arrest due to metabolic acidosis. Failures included an unlabelled blood sample, omission of an ECG, and inadequate communication of the patient’s condition and emergency level to ambulance control. The report raised concerns about communication arrangements between healthcare staff, prison control rooms and ambulance control, including the possibility of a wider national problem.
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 effective communication between healthcare personnel at medical emergencies and prison or ambulance control
Wider context from the report “(1) The evidence disclosed the need for healthcare and the prison to devise a better means of communication between healthcare personnel at the scene of a medical emergency and the prison control room / ambulance control
(2) Similar communication difficulties have already been reported in relation to the inquest into the death of Martin Brown who died at HMIP Lancaster Farms and the Prison and Probation Ombudsman has highlighted a delay in the provision of essential information to Ambulance Control in the case of ████████ who died on 9th December 2020 at HMP Garth
(3) The fact that communication difficulties have arisen between healthcare and the ambulance service in three recent cases involving prisons in Lancashire may indicate a potentially national problem
” Open source report
22 Dec 2021 Mark Castley · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 1 Failure to fully assess recurrent impulsive self-harm risks in post-sentencing situations View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mark Castley · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mark Castley died by suicide on 26 June 2019 in St Thomas Hospital after bringing a ████████ into court. The inquest jury identified non-completion of a suicide risk form by the probation officer and non-confiscation of the ████████ by the dock officer as contributing factors. The report raises concern that risks of recurrent impulsive self-harm in the context of sentencing were not fully assessed and that the relevant policy may have required or been interpreted as requiring imminence of risk.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to fully assess recurrent impulsive self-harm risks in post-sentencing situations
Wider context from the report “The evidence suggests that his risks of recurrent impulsive self harm in situations his ex wife described as “when he is cornered” were not fully assessed as applying to the time after he was being sentenced and if they had been, a notification form might have been completed. Whether this was due to the policy requiring imminence of risk at the time of assessment or being erroneously interpreted so, or whether the projection of imminence arising in a future context was not fully considered , is not clear.
” 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 Remind London probation staff to follow the risk-to-self process maps and complete a Suicide Risk Form when a current concern is identified.
Verbatim wording from the response “3) All probation staff in London have been reminded of the requirement to adhere to the ‘probation risk to self’ EQUiP process maps, including the completion of the Suicide Risk Form, where a current concern is identified. This directive will also be disseminated across the Probation Service nationally.” 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 Disseminate the directive on following risk-to-self process maps and completing Suicide Risk Forms across the Probation Service nationally.
Verbatim wording from the response “3) All probation staff in London have been reminded of the requirement to adhere to the ‘probation risk to self’ EQUiP process maps, including the completion of the Suicide Risk Form, where a current concern is identified. This directive will also be disseminated across the Probation Service nationally.” Source location Response from HM Prison and Probation Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Add guidance to the EQUiP process map directing court staff to complete a Suicide Risk Form when a current concern is identified.
Verbatim wording from the response “2) The text above in brackets has now also been added to the Probation EQUiP process map for court staff to trigger the completion of a Suicide Risk Form where a concern has been identified. The Probation Service use a process called EQUiP which holds all national policies, processes and guidance, including process maps.” 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 Revise the probation suicide and self-harm guide to assess current suicide-risk concerns and relevant historic information.
Verbatim wording from the response “1) Appendix 1 of the ‘Working with Suicide & Self-Harm; A Guide for Probation Staff’ has been reviewed and the question ‘is there an immediate risk of suicide’ has been changed to ‘has a current concern relating to suicide risk been identified’ (staff are reminded to consider historic information which could be relevant to, or triggered by current circumstances).” Source location Response from HM Prison and Probation Service
Open published response
22 Dec 2021 Kyle Nel · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 4 Failure to provide a formal written response to family or friends raising prisoner health or welfare concerns View source Failure of prison security fences to prevent the transfer of drugs and other prohibited materials between prisoners View source Failure to keep a computer record of family or friend concerns and measures taken to address them View source Failure to use a structured approach for responding to family or friend concerns about prisoner health or welfare View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Kyle Nel · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Kyle Nel, a serving prisoner at HMP Guys Marsh, was found unconscious in his cell on 9 June 2018 and was subsequently declared dead after resuscitation attempts. The inquest recorded the medical cause of death as aspiration of gastric contents associated with synthetic cannabinoid (5F-ADB), also known as “Spice”, use, with a conclusion of misadventure. Concerns included the prison’s handling and recording of welfare concerns raised by families and the ability to pass drugs and other prohibited items between prison units through security fences.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to provide a formal written response to family or friends raising prisoner health or welfare concerns
Wider context from the report “i) I have concerns that when members of a prisoner’s family or friends contact the prison raising concerns as to the health or welfare of a prisoner, there needs to be structured approach and computer record kept of those concerns, the measures taken to deal with the concerns and a formal written response to the family or friends who have raised those concerns . It is understood that while there are potential security and confidentiality issues that may arise from this process suitable measures should be considered and implemented.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure of prison security fences to prevent the transfer of drugs and other prohibited materials between prisoners
Wider context from the report “ii) The security fences within the prison estate need to be reviewed and consideration urgently given to prevent drugs and other prohibited materials being passed between prisoners through the fences .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to keep a computer record of family or friend concerns and measures taken to address them
Wider context from the report “i) I have concerns that when members of a prisoner’s family or friends contact the prison raising concerns as to the health or welfare of a prisoner, there needs to be structured approach and computer record kept of those concerns, the measures taken to deal with the concerns and a formal written response to the family or friends who have raised those concerns. It is understood that while there are potential security and confidentiality issues that may arise from this process suitable measures should be considered and implemented.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to use a structured approach for responding to family or friend concerns about prisoner health or welfare
Wider context from the report “i) I have concerns that when members of a prisoner’s family or friends contact the prison raising concerns as to the health or welfare of a prisoner, there needs to be structured approach and computer record kept of those concerns, the measures taken to deal with the concerns and a formal written response to the family or friends who have raised those concerns. It is understood that while there are potential security and confidentiality issues that may arise from this process suitable measures should be considered and implemented.
” Open source report
×
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 Respond to families and friends with updates about actions taken on their concerns, subject to security limitations.
Verbatim wording from the response “Custody hotline and mailbox contains an out of office message with instructions on how to raise an emergency concern out of hours. All concerns raised are now logged on a database, managed by the Safer Custody team, along with a record of the action taken, and a note is placed on the individual’s NOMIS record so that information regarding a prisoner’s risk is shared with all relevant staff. The Safer Custody team respond to any concerns raised by families and friends, providing an update on what has happened and what actions have been taken. Of course, there are instances where staff are not able to provide detail for security reasons but in these circumstances an explanation is provided to families in line with the HMPPS policy framework on Strengthening Prisoners’ Family Ties.” Source location 2021-0426-Response-from-HMPPS_Published
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 diagnostic checks of internal and external perimeters, including fences and gates, to identify drug-supply vulnerabilities and report findings to establishments.
Verbatim wording from the response “The national Drug Strategy and Delivery team conduct diagnostic visits, checking internal and external perimeters (including fences and gates), to identify any vulnerabilities relating to drug dealing which are reported back to establishments to take action. HMP Guys Marsh has also been included in the accelerator project, where selected prisons have received additional resources in certain areas. At HMP Guys Marsh this includes a dedicated drug strategy manager who has been in place since Autumn 2021 and is making a positive impact on the local drug strategy processes. The project has now received additional funding and will be extended for three years to further support efforts to tackle the problem of drugs in prisons.” Source location 2021-0426-Response-from-HMPPS_Published
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 Log family and friend concerns, record actions taken, and share relevant risk information on prisoners’ NOMIS records.
Verbatim wording from the response “Custody hotline and mailbox contains an out of office message with instructions on how to raise an emergency concern out of hours. All concerns raised are now logged on a database, managed by the Safer Custody team, along with a record of the action taken, and a note is placed on the individual’s NOMIS record so that information regarding a prisoner’s risk is shared with all relevant staff. The Safer Custody team respond to any concerns raised by families and friends, providing an update on what has happened and what actions have been taken. Of course, there are instances where staff are not able to provide detail for security reasons but in these circumstances an explanation is provided to families in line with the HMPPS policy framework on Strengthening Prisoners’ Family Ties.” Source location 2021-0426-Response-from-HMPPS_Published
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 security fences at HMP Guys Marsh meet agreed national requirements, so further review is not identified as necessary.
Verbatim wording from the response “The second concern you raise recommends that consideration should be given to reviewing the security fences used within the prison estate to prevent drugs and other prohibited items from being passed between prisoners. As a category C prison, the security fences in place at HMP Guys Marsh meet the current agreed national requirements necessary to keep prisoners safe and secure. I wish to assure you that the work being carried out nationally by the Drug Strategy Team and filtered down into each establishment is focused on restricting the supply of drugs in prisons, supporting prisoners to reduce and avoid substance misuse, and providing the help and treatment they need to maintain their recovery.” Source location 2021-0426-Response-from-HMPPS_Published
Open published response
22 Oct 2021 Anthony John Larcher · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 5 Failure of SystmOne to make vital prison healthcare information readily identifiable View source Failure to identify prisoners’ health information during large-cohort reception View source Lack of observations and welfare checks for prisoners found under the influence of psychoactive substances View source Lack of healthcare staff attendance at ACCT reviews View source Lack of 24-hour healthcare across the prison estate 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
Anthony John Larcher · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 21 March 2018, Anthony John Larcher, a serving prisoner at HMP Guys Marsh, was found in his cell. The report identifies concerns about monitoring prisoners under the influence of psychoactive substances, the lack of round-the-clock healthcare, healthcare involvement in ACCT reviews, the accessibility of medical information, and the reception of prisoners arriving in large cohorts.
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 SystmOne to make vital prison healthcare information readily identifiable
Wider context from the report “iv. I am concerned that vital information contained within a prisoner’s medical health records stored on SystmOne, could be missed due to fact the software is more adapted to GP practice than prison healthcare . This could result in a future death and I request consideration is given to adapting SystmOne for better use in prisons to ensure information, especially where there are complex care needs, is easily assessable and highlighted to avoid crucial information regarding a patient’s care and safety being missed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 prisoners’ health information during large-cohort reception
Wider context from the report “v. I have concerns with the movement of prisoners around the prison estate in large cohorts as it could result in information regarding a prisoner’s health not being identified which could result in a lack of healthcare provision to the prisoner which could result in a future death. I therefore request that consideration be given to the review of the processes when large cohorts are received at prisons and the resources available to prison and healthcare staff prior to the arrival of the prisoner and during the progression of the prisoners through the reception 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 observations and welfare checks for prisoners found under the influence of psychoactive substances
Wider context from the report “i. There could be future deaths across the prison estate nationally due to a lack of observations and welfare checks upon prisoners who are found under the influence of Spice and I request consideration be given to the rolling out of the local processes adopted at HMP Guys Marsh, nationally. This includes the roll out of their Welfare Checks Policy, the Persistent Psychoactive Substances Intervention Plan (PPSIP) and the Custodial Officer Intermediate Life Support initiative (COILS).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 healthcare staff attendance at ACCT reviews
Wider context from the report “iii. I have concerns that future deaths could occur due to the lack of attendance of healthcare staff at ACCT reviews, especially where the ACCT is closed . I request that consideration is given to providing guidance nationally by way of a safety bulletin or an update to the ACCT version 6 guidance and in the new PSI to be released in the future on the policy on management of prisoners at risk of harm to self, to others and from others, ensuring the attendance of healthcare staff at all ACCT reviews.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Lack of 24-hour healthcare across the prison estate
Wider context from the report “ii. I have concerns that future deaths could occur due to the lack of 24 hour healthcare across the prison estate . I would therefore request consideration be given to the provision of healthcare to all prisons 24 hours a day, 7 days a week.
” 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 Roll out revised ACCT training modules nationally for staff involved in ACCT delivery.
Verbatim wording from the response “reviews in person, however, where this is not possible they can still contribute through the written contribution form which is included in the ACCT documentation. ACCT user guidance was issued to all establishments in advance of the roll out of ACCT v6 to ensure that staff were familiar with the new version and confident with the key changes made to the document. All establishments were provided with bite size awareness training packages to deliver to staff and upskilling materials to equip staff with the necessary skills to complete ACCT v6, and revised training modules are being rolled out nationally for all staff involved in the delivery of ACCT.” Source location 2021-0356-Response-from-HMPPS_Published
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 Transfer prisoners in smaller numbers as pandemic-related exceptional delivery measures are withdrawn.
Verbatim wording from the response “The third concern you have raised is that, as a result of the pandemic, prisoners have been arriving into prisons in large cohorts and this has put additional pressure on the reception procedures for prison and healthcare staff. While I recognise that this added to the pressures on staff assessing prisoners coming into prison, this has been necessary in order to keep prisoners safe, manage infection rates in line with public health advice, and to ensure that prisoners are receiving as full a regime as possible. This has only been possible through a cohort of prisoners arriving into prisons at the same time to begin a period of reverse cohorting together. As we begin to move away from the exceptional delivery measures, efforts are being made to transfer prisoners in smaller numbers and the aim is to return to standard delivery as was in place pre-pandemic.” Source location 2021-0356-Response-from-HMPPS_Published
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 ACCT v6 guidance and provide awareness and upskilling materials to establishments and staff.
Verbatim wording from the response “reviews in person, however, where this is not possible they can still contribute through the written contribution form which is included in the ACCT documentation. ACCT user guidance was issued to all establishments in advance of the roll out of ACCT v6 to ensure that staff were familiar with the new version and confident with the key changes made to the document. All establishments were provided with bite size awareness training packages to deliver to staff and upskilling materials to equip staff with the necessary skills to complete ACCT v6, and revised training modules are being rolled out nationally for all staff involved in the delivery of ACCT.” Source location 2021-0356-Response-from-HMPPS_Published
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 Roll out ACCT v6 nationally with multidisciplinary case reviews and healthcare attendance or written contributions where relevant.
Verbatim wording from the response “The second concern you raise is in relation to healthcare attendance at ACCT reviews. I understand that evidence was heard at the inquest about the new version of ACCT (ACCT v6) which was rolled out nationally in July 2021. The ACCT v6 guidance is clear that case reviews must be multi-disciplinary and that healthcare staff must be invited to attend the first ACCT case review, as well any subsequent reviews where healthcare involvement is relevant to supporting an individual. Attendance at case reviews must be driven by the individual’s specific needs and support required to ensure consistency and continuity of care as the case review team work together to drive meaningful outcomes and take ownership for their agreed Support Actions. Team members should try to attend case” Source location 2021-0356-Response-from-HMPPS_Published
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 Discuss nationally rolling out local drug-related safety initiatives with the NHSE/I national team.
Verbatim wording from the response “The first concern you raise is that there could be future deaths across the prison estate due to a lack of observations and welfare checks on prisoners who are found under the influence of illicit psychoactive substances, and you have requested that consideration be given to a national roll out of some of the local initiatives which have been implemented at HMP Guys Marsh. The national Drug Strategy Team have been in touch with regional prison safety groups to gather information on the local initiatives which have been implemented around the country, including those in place at HMP Guys Marsh, and are in talks with NHSE/I national team about rolling out some of these initiatives on a national scale. We are committed to learning from local practices and to use these to inform the development of national policies to drive improvement and work to save lives and keep people safe.” Source location 2021-0356-Response-from-HMPPS_Published
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 Gather information from regional prison safety groups about local initiatives for observations and welfare checks.
Verbatim wording from the response “The first concern you raise is that there could be future deaths across the prison estate due to a lack of observations and welfare checks on prisoners who are found under the influence of illicit psychoactive substances, and you have requested that consideration be given to a national roll out of some of the local initiatives which have been implemented at HMP Guys Marsh. The national Drug Strategy Team have been in touch with regional prison safety groups to gather information on the local initiatives which have been implemented around the country, including those in place at HMP Guys Marsh, and are in talks with NHSE/I national team about rolling out some of these initiatives on a national scale. We are committed to learning from local practices and to use these to inform the development of national policies to drive improvement and work to save lives and keep people safe.” Source location 2021-0356-Response-from-HMPPS_Published
Open published response
25 May 2021 James Devenny · Prevention of Future Deaths report Mid Kent and Medway
View report summary
Concerns raised 4 Failure to routinely brief Prison Officers about prisoners’ previous significant self-harm in custody View source Lack of direct and immediate access to telephone, listening and chaplaincy support for prisoners View source Unclear threshold for informing prison staff about significant self-harm risk View source Failure to routinely brief Prison Officers about prisoners’ antecedent patterns leading to significant self-harm View source See 1 more concern
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. 5
Action
Provide in-cell telephony at HMP Elmley, resolving handset supply issues except for Care and Separation Unit and healthcare in-patients.
Stated completedThe respondent said that this action was complete when they made their response on 27 May 2021. View source
Action
Maintain dedicated Samaritans phones in wing offices, updating them for visibility, programming them exclusively for Samaritans, and checking their operation.
Stated completedThe respondent said that this action was complete when they made their response on 27 May 2021. View source
Action
Implement ACCT version 6 across the male estate, including strengthened risk-identification requirements and revised staff training and awareness materials.
Stated completedThe respondent said that this action was complete when they made their response on 27 May 2021. View source
Action
Provide and routinely use an updated safety diagnostic tool consolidating violence, self-harm and other relevant risk information for staff.
Stated completedThe respondent said that this action was complete when they made their response on 27 May 2021. View source
Action
Operate the Key Worker scheme, providing each person in custody with a dedicated worker and weekly meetings to identify risks, triggers and changes in self-harm or suicide risk.
Stated completedThe respondent said that this action was complete when they made their response on 27 May 2021. View source See 2 more actions
×
AI-generated summary
James Devenny · 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
James Devenny died in his cell at HMP Elmley on 2 September 2019, having been found hanging from a light fitting using a bedsheet ligature. The jury identified concerns including staff not being aware of his previous self-harm history, the absence of a medical assessment before his separation from other prisoners, an inappropriate response to mental health referrals, and inadequate access to phones and support services. The report also records concerns about prison officers not being routinely briefed about prisoners’ previous significant self-harm and related patterns of thoughts, feelings, events and behaviours.
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 routinely brief Prison Officers about prisoners’ previous significant self-harm in custody
Wider context from the report “(2) Prison Officers are not routinely briefed as to prisoners who have previously significantly self harmed in custody . It is not clear as to the threshold of severity required before prison staff will be informed sae that they will be informed if a prisoner arrives with an open ACCT. Prison Officers are not routinely briefed as to a prisoner’s previous or antecedent pattern of thoughts, feelings, events and behaviours which have led to incidents of significant self-harm.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 direct and immediate access to telephone, listening and chaplaincy support for prisoners
Wider context from the report “(1) In the absence of telephones which are installed directly into the cell, there is no direct means for a prisoner to contact the Samaritans . In the event that a prisoner does not have access to a telephone they are reliant on staff to convey them to a telephone so they may call . There is a particular difficulty in respect of prisoners who are deemed to pose a risk of violence and who may not be able to immediately access a telephone, a listener or a member of Chaplaincy .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 threshold for informing prison staff about significant self-harm risk
Wider context from the report “(2) Prison Officers are not routinely briefed as to prisoners who have previously significantly self harmed in custody. It is not clear as to the threshold of severity required before prison staff will be informed sae that they will be informed if a prisoner arrives with an open ACCT . Prison Officers are not routinely briefed as to a prisoner’s previous or antecedent pattern of thoughts, feelings, events and behaviours which have led to incidents of significant self-harm.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 routinely brief Prison Officers about prisoners’ antecedent patterns leading to significant self-harm
Wider context from the report “(2) Prison Officers are not routinely briefed as to prisoners who have previously significantly self harmed in custody. It is not clear as to the threshold of severity required before prison staff will be informed sae that they will be informed if a prisoner arrives with an open ACCT. Prison Officers are not routinely briefed as to a prisoner’s previous or antecedent pattern of thoughts, feelings, events and behaviours which have led to incidents of significant self-harm .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide in-cell telephony at HMP Elmley, resolving handset supply issues except for Care and Separation Unit and healthcare in-patients.
Verbatim wording from the response “At the time of Mr Devenny’s death, in-cell telephony had only recently been introduced at HMP Elmley, and there were initially some supply issues which meant that not all cells were equipped with the necessary handsets. These have now been resolved, and with the exception of those in the Care and Separation Unit (CSU) and Healthcare in-patients, all those in custody at HMP Elmley now have in-cell phones.” Source location 2021-0179-Response-from-HMPPS_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain dedicated Samaritans phones in wing offices, updating them for visibility, programming them exclusively for Samaritans, and checking their operation.
Verbatim wording from the response “All people in custody across the prison estate are able to call Samaritans without charge using a pin number given out on induction and widely circulated around the prison. In the event that in-cell telephony is unavailable, individuals can also request the dedicated Samaritans phones that are held in each wing office and are taken to people in their cells. These phones have been updated, and the handsets are now bright green, as a visual association with the colours used by the Samaritans and to make them more visible to staff so that they can be quickly identified and provided once requested. These phones are programmed with only the Samaritans phone number and staff check them regularly to ensure that they are in full working order.” Source location 2021-0179-Response-from-HMPPS_Published
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 ACCT version 6 across the male estate, including strengthened risk-identification requirements and revised staff training and awareness materials.
Verbatim wording from the response “You will recall that evidence was given at the inquest about the updated version of Assessment Care in Custody and Teamwork version 6 (ACCT v6), which was due to be rolled out shortly after the inquest. I am pleased to confirm that ACCT v6 went live across the male estate in July 2021. Along with updates and improvements made to the ACCT document there is also an increased emphasis placed on up-skilling staff in relation to risk identification, and revised training modules and awareness materials have been made available to all staff at the prison.” Source location 2021-0179-Response-from-HMPPS_Published
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 and routinely use an updated safety diagnostic tool consolidating violence, self-harm and other relevant risk information for staff.
Verbatim wording from the response “An updated safety diagnostic tool which provides information about individuals is available to all staff. This includes information on violence and self-harm, and other relevant information drawn from NOMIS. The tool makes it easier to access all relevant risk information in one place and is routinely used by safer custody staff who flag any new receptions and any individuals they are concerned about to wing staff and other relevant departments within the prison.” Source location 2021-0179-Response-from-HMPPS_Published
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 the Key Worker scheme, providing each person in custody with a dedicated worker and weekly meetings to identify risks, triggers and changes in self-harm or suicide risk.
Verbatim wording from the response “The prison also now operates the Key Worker scheme, whereby all people in custody have a dedicated Key Worker who meets with them on a weekly basis. The intention of Key Work is to enable better relationships between staff and people in prison, and to support those in custody to settle into prison life. Key Workers are expected to be aware of an individual’s history and to work with them to help and support them with any issues. As part of this role key workers review National Offender Management Information System (NOMIS) case notes and look at any previous issues or risks, including self-harm. They are therefore well placed to recognise any changes in the level of an individual’s risk of self-harm or suicide and to be aware of any potential trigger dates which may indicate that an ACCT should be opened to provide increased support.” Source location 2021-0179-Response-from-HMPPS_Published
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 arrangements provide access to Samaritans by in-cell phones or dedicated wing phones when in-cell telephony is unavailable.
Verbatim wording from the response “At the time of Mr Devenny’s death, in-cell telephony had only recently been introduced at HMP Elmley, and there were initially some supply issues which meant that not all cells were equipped with the necessary handsets. These have now been resolved, and with the exception of those in the Care and Separation Unit (CSU) and Healthcare in-patients, all those in custody at HMP Elmley now have in-cell phones.” Source location 2021-0179-Response-from-HMPPS_Published
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 Previous self-harm incidents will not always be relevant to identifying current self-harm risks and triggers.
Verbatim wording from the response “Your second concern is that prison officers are not routinely briefed about people who have previously significantly self-harmed in custody. While a knowledge of previous self-harm can be useful, and this information will be noted if it is available either on “National Offender Management Information System” the system used for informing about those in custody, or disclosed by the individual in question, previous incidents will not always be relevant in identifying current risks and triggers. As HMP Elmley is a busy local prison with a high turnover of people in their care, there is a focus on recognising risk and triggers for self-harm and suicide and being alert to any changes in an individual which may indicate an increase in risk.” Source location 2021-0179-Response-from-HMPPS_Published
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 risk-recognition practices focus staff on current self-harm and suicide risks and changes indicating increased risk.
Verbatim wording from the response “Your second concern is that prison officers are not routinely briefed about people who have previously significantly self-harmed in custody. While a knowledge of previous self-harm can be useful, and this information will be noted if it is available either on “National Offender Management Information System” the system used for informing about those in custody, or disclosed by the individual in question, previous incidents will not always be relevant in identifying current risks and triggers. As HMP Elmley is a busy local prison with a high turnover of people in their care, there is a focus on recognising risk and triggers for self-harm and suicide and being alert to any changes in an individual which may indicate an increase in risk.” Source location 2021-0179-Response-from-HMPPS_Published
Open published response
12 Feb 2021 Michael Dent-Jones · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 1 Failure of Approved Premises staff to be familiar with and apply Safe Working Practices Document guidance on resident safety View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Michael Dent-Jones · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Michael Dent-Jones was found deceased at St Catherine’s Priory on 14 July 2018 after an unintentional Tramadol overdose. The report identifies concerns that Approved Premises staff may not have been familiar with or applying guidance on the delivery and collection of residents’ prescribed medication and other resident-safety procedures.
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 Approved Premises staff to be familiar with and apply Safe Working Practices Document guidance on resident safety
Wider context from the report “Accordingly I am concerned that:
- Staff at St Catherine’s Priory Approved Premises in Guildford, as well as staff in other Approved Premises nationally, may not be familiar with, or applying, the guidance set out in the Safe Working Practices Document in relation to the delivery/collection of residents’ prescribed medication, but also more generally in relation to the other policies and procedures pertaining to resident safety in that document.
- Staff at St Catherine’s Priory Approved Premises in Guildford, as well as staff in other Approved Premises nationally, may not be familiar with, or applying, the guidance set out in the Safe Working Practices Document in relation to the delivery/collection of residents’ prescribed medication, but also more generally in relation to the other policies and procedures pertaining to resident safety in that document.
” 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 Approved Premises Managers to update local Safe Working Practices using the re-issued template.
Verbatim wording from the response “The national SWP template has recently been reviewed and is due to be re-issued on the 30th April 2021 to all Approved Premises Managers for local update by the middle of June 2021. Part of this process includes an instruction that every staff member working in an Approved Premises, including agency staff must read the updated SWP and sign a locally held Register to confirm this and also that they understand the processes which must be followed at all times. These Registers are managed by the Approved Premises Manager and assurance that all relevant staff have signed off the Register will” Source location 2021-0041-Response-from-HMPS-Redacted
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 reviewed national Safe Working Practice template to all Approved Premises Managers.
Verbatim wording from the response “The national SWP template has recently been reviewed and is due to be re-issued on the 30th April 2021 to all Approved Premises Managers for local update by the middle of June 2021. Part of this process includes an instruction that every staff member working in an Approved Premises, including agency staff must read the updated SWP and sign a locally held Register to confirm this and also that they understand the processes which must be followed at all times. These Registers are managed by the Approved Premises Manager and assurance that all relevant staff have signed off the Register will” Source location 2021-0041-Response-from-HMPS-Redacted
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 all Approved Premises staff, including agency staff, to read the updated Safe Working Practice and sign a register confirming understanding.
Verbatim wording from the response “The national SWP template has recently been reviewed and is due to be re-issued on the 30th April 2021 to all Approved Premises Managers for local update by the middle of June 2021. Part of this process includes an instruction that every staff member working in an Approved Premises, including agency staff must read the updated SWP and sign a locally held Register to confirm this and also that they understand the processes which must be followed at all times. These Registers are managed by the Approved Premises Manager and assurance that all relevant staff have signed off the Register will” Source location 2021-0041-Response-from-HMPS-Redacted
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 assurance that relevant Approved Premises staff have signed the Safe Working Practice register through Area Managers and operational Residential Heads.
Verbatim wording from the response “The national SWP template has recently been reviewed and is due to be re-issued on the 30th April 2021 to all Approved Premises Managers for local update by the middle of June 2021. Part of this process includes an instruction that every staff member working in an Approved Premises, including agency staff must read the updated SWP and sign a locally held Register to confirm this and also that they understand the processes which must be followed at all times. These Registers are managed by the Approved Premises Manager and assurance that all relevant staff have signed off the Register will” Source location 2021-0041-Response-from-HMPS-Redacted
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 Audit all Approved Premises safe working practices to verify accurate local medication delivery and collection information.
Verbatim wording from the response “The national Safe Working Practice (SWP) document for all Approved Premises was first introduced in December 2018 having been approved by the National Approved Premises Continuous Improvement Governance Board. The purpose of this document is to ensure consistency of approach and includes a section on Medication and in particular the delivery/collection of residents’ prescribed medication. Following the conclusion of the Inquest, the Head of the National Approved Premises Team undertook an audit of all SWPs to ensure each and every one contained correct and relevant local information about the delivery/collection of residents’ prescribed medication.” Source location 2021-0041-Response-from-HMPS-Redacted
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 Approved Premises staff usage data for EQuiP to identify locations with below-average usage.
Verbatim wording from the response “The National Approved Premises Team will review the EQuiP usage data for approved premises staff to identify any areas where EQuiP usage falls below average and will undertake (over the next six months to September 2021), an awareness raising exercise to reinforce the importance of EQuiP as the reference source of information for all approved premises policies and procedures.” Source location 2021-0041-Response-from-HMPS-Redacted
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 an awareness-raising exercise reinforcing EQuiP as the reference source for Approved Premises policies, guidance and procedures.
Verbatim wording from the response “The National Approved Premises Team will review the EQuiP usage data for approved premises staff to identify any areas where EQuiP usage falls below average and will undertake (over the next six months to September 2021), an awareness raising exercise to reinforce the importance of EQuiP as the reference source of information for all approved premises policies and procedures.” Source location 2021-0041-Response-from-HMPS-Redacted
Open published response
Concerns raised 3 Failure of the prisoner arrival form to sufficiently highlight self-harm and suicide risk to wing staff View source Lack of robust management audit of nightly roll checks View source Failure of the prisoner arrival form to provide a clear self-harm and suicide risk assessment and response pathway View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jason O’Rourke · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Jason O’Rourke died by suicide in his cell at HMP Belmarsh after hanging himself with a bedsheet ligature between 7.28 pm on 1 April 2019 and 9.33 am on 2 April 2019. The jury identified possible contributing factors including inadequate follow-up of his mental health, insufficient sharing and understanding of information about his mental health and self-harm history, and inadequate safety intervention meetings. The report also raised concerns about unclear self-harm and suicide risk assessments on arrival and the lack of robust auditing of nightly roll 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 Failure of the prisoner arrival form to sufficiently highlight self-harm and suicide risk to wing staff
Wider context from the report “(1) The ‘immediate needs’ form completed for prisoners on arrival at HMP Belmarsh does not facilitate a clear assessment of any risk of self-harm or suicide and the actions to be taken if such a risk is identified.
The form poses a question: “Is there any specific concerns re self-harm or suicide?” and then gives the guidance “if yes, amend care plan”. However, this guidance is only effective for those prisoners who already have a care plan, meaning those who are already on an Open Assessment, Care in Custody and Teamwork (‘ACCT’) plan. The action to be taken for those prisoners where specific concerns regarding self-harm or suicide are identified, but who do not already have a care plan, is unclear from the form.
It is also unclear how the above question interacts with further questions below it which address any past ACCTs/F2052SHs, the level of support available to the prisoner and the answer the prisoner gives to the question “Do you feel suicidal now?”
Accordingly, this form does not sufficiently highlight prisoners who are in fact suicidal, or where there are concerns about their risk of self-harm or suicidal, to those on the wing.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 robust management audit of nightly roll checks
Wider context from the report “(2) The nightly roll checks at HMP Belmarsh are due to be carried out by a single member of Operational Support Grade (OSG) staff at 9.00 pm and 6.00 am. Their stated purpose is to check for escape or death among the prisoners. On handing over to the morning staff, the OSG signs paperwork indicating that the roll checks have been completed. There is no robust system by which the prison management audit this process. This means that the prison management can be under the impression that the checks have been carried out, when they have not been , as occurred here.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 prisoner arrival form to provide a clear self-harm and suicide risk assessment and response pathway
Wider context from the report “(1) The ‘immediate needs’ form completed for prisoners on arrival at HMP Belmarsh does not facilitate a clear assessment of any risk of self-harm or suicide and the actions to be taken if such a risk is identified .
The form poses a question: “Is there any specific concerns re self-harm or suicide?” and then gives the guidance “if yes, amend care plan”. However, this guidance is only effective for those prisoners who already have a care plan, meaning those who are already on an Open Assessment, Care in Custody and Teamwork (‘ACCT’) plan. The action to be taken for those prisoners where specific concerns regarding self-harm or suicide are identified, but who do not already have a care plan, is unclear from the form.
It is also unclear how the above question interacts with further questions below it which address any past ACCTs/F2052SHs, the level of support available to the prisoner and the answer the prisoner gives to the question “Do you feel suicidal now?”
Accordingly, this form does not sufficiently highlight prisoners who are in fact suicidal, or where there are concerns about their risk of self-harm or suicidal, to those on the wing.
” 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 Visit Belmarsh to identify further roll-check improvements and test compliance with the new process and Local Security Strategy.
Verbatim wording from the response “In the light of the concerns that you have expressed, the Governor of HMP Belmarsh is working with the Long Term and High Security Estate (LTHSE) safety team to review the quality assurance processes in place for roll checks. As a first step, a system has been implemented whereby when a night OSG arrives a discipline officer remains on the wing until a full roll check has been completed, recorded and signed for on the wing and reported to the Orderly Officer. Spot checks are in place to ensure that the process is being followed. The LTHSE safety team will be visiting Belmarsh to identify further opportunities for improvement and to test compliance with this new process, and the LSS more generally.” Source location 2021-0032-Response-from-HMPPS-Redacted
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 a discipline officer to remain on the wing until each night OSG roll check is completed, recorded, signed and reported, with spot checks of compliance.
Verbatim wording from the response “In the light of the concerns that you have expressed, the Governor of HMP Belmarsh is working with the Long Term and High Security Estate (LTHSE) safety team to review the quality assurance processes in place for roll checks. As a first step, a system has been implemented whereby when a night OSG arrives a discipline officer remains on the wing until a full roll check has been completed, recorded and signed for on the wing and reported to the Orderly Officer. Spot checks are in place to ensure that the process is being followed. The LTHSE safety team will be visiting Belmarsh to identify further opportunities for improvement and to test compliance with this new process, and the LSS more generally.” Source location 2021-0032-Response-from-HMPPS-Redacted
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 quality-assurance processes for roll checks with the LTHSE safety team.
Verbatim wording from the response “In the light of the concerns that you have expressed, the Governor of HMP Belmarsh is working with the Long Term and High Security Estate (LTHSE) safety team to review the quality assurance processes in place for roll checks. As a first step, a system has been implemented whereby when a night OSG arrives a discipline officer remains on the wing until a full roll check has been completed, recorded and signed for on the wing and reported to the Orderly Officer. Spot checks are in place to ensure that the process is being followed. The LTHSE safety team will be visiting Belmarsh to identify further opportunities for improvement and to test compliance with this new process, and the LSS more generally.” Source location 2021-0032-Response-from-HMPPS-Redacted
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 a revised immediate-needs form with clearer guidance for identifying, communicating and documenting suicide or self-harm risks.
Verbatim wording from the response “Following evidence heard at the inquest you have raised concerns in relation to the ‘immediate needs’ form completed for prisoners on arrival at HMP Belmarsh. This is a locally produced document created in line with the Prison Service Instruction (PSI) 07/2015 Early days in Custody. You will be aware that the early days in custody is a period in which risk of self-harm or suicide is heightened and the wellbeing of prisoners in our care is the primary concern of staff throughout the reception and first night process. Following the inquest a review of the form has taken place, and a new version is now in use.” Source location 2021-0032-Response-from-HMPPS-Redacted
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 Routine CCTV monitoring cannot be used to assure roll checks because CCTV is authorised only for specified safety, security or investigative circumstances.
Verbatim wording from the response “I understand that the question of using CCTV for assurance was explored at the inquest. CCTV is deployed in prisons for reasons of safety and security and not for general surveillance or monitoring staff performance. Playback of CCTV coverage is only authorised in certain circumstances, such as where there is reason to believe that safety or security has been compromised, or to assist with a formal investigation. Where there is suspicion that roll checks are not being carried out, CCTV could be used as part of an investigation into those suspicions, but it cannot routinely be monitored as part of the assurance process. 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.” Source location 2021-0032-Response-from-HMPPS-Redacted
Open published response
Includes reports addressed to a minister or senior office-holder acting for this organisation.
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations