Concerns raised 1 Failure of investigations to verify the accuracy of relevant attendance records View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Connor Steven Paul 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
Connor Steven Paul Smith, aged 20, died in custody at HMP Altcourse in the early hours of 2 January 2013 after being found hanging from a bed sheet; resuscitation was unsuccessful. The report identifies a concern about the quality of the PPO investigation, because a prison custody officer was recorded as attending a review hearing despite not being present, potentially hindering learning in another case.
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 investigations to verify the accuracy of relevant attendance records
Wider context from the report “On the 28th January 2013 the PPO investigator interviewed a PCO with regard to a review hearing under rule 49 - colloquially known as a rule 45 board. The officer was asked about the record of the meeting in which his name had appeared as an attendee. Given the frequency of such meetings the officer could not remember the meeting on the 1st January 2013 but was interviewed about it creating a 15 page transcript. On examination of other witnesses, other documentary evidence and a video of the meeting made it clear that the PCO was not present at the review hearing – his name had been entered on the Segregation Rule 45/Rule 49 Authority for continued segregation before the meeting but he had not been there.
This is an area of concern highlighting the quality of the investigation by the PPO where by such an error could in another case prevent lessons from being learnt.
” 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 senior managers guidance requiring meeting attendance records to be completed accurately and without pre-entered names.
Verbatim wording from the response “I understand that your concern relates to the quality of the investigation by the Prisons and Probation Ombudsman. However in raising that concern you have drawn attention to the fact that a member of staff was recorded as having attended a meeting at which he was not present, and I would like to provide reassurance that this issue has been addressed by the Director of HMP Altcourse. A notice has been issued to all senior managers who chair Segregation Review Boards advising them that the documentation for completion at the meeting must not have names entered in advance and that it is their responsibility to check that attendance at the meeting is correctly recorded.” Source location 2014-0540-Response-by-NOMS
Open published response
Concerns raised 4 Failure to give sufficient weight to mental health staff opinions in ACCT reviews View source Failure of ACCT review members to read the ACCT document before reviews View source Failure to ensure mental health staff attend relevant ACCT reviews View source Failure to share mental health information with other ACCT review members 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
Geraldine Liege Kilborn · 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
Geraldine Liege Kilborn died in HMP Low Newton after repeatedly self-harming over the 22 days following her reception into the prison; the Jury could not determine her intention when she hung herself. The principal concerns were inadequate sharing and weighting of mental-health information during ACCT reviews, limited review of ACCT records by some panel members, and questions about review-panel membership and her location at the time of death.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to give sufficient weight to mental health staff opinions in ACCT reviews
Wider context from the report “(1) There was a clear breakdown in sharing of information known to the mental health team with other members of some ACCT reviews. Evidence was given that there has been a change in service provision contracts since the death of the deceased and that mental health staff will now work weekends. Nevertheless, it is vital that in appropriate cases where a prisoner is on an ACCT and has had substantial mental health input that they both attend relevant ACCT reviews and their opinions are given sufficient weight . It is noted that mental health nurses never chair such ACCT reviews as case manager and in this case has revealed that even in attendance, their views might not be given sufficient weight .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 review members to read the ACCT document before reviews
Wider context from the report “(2) Witnesses confirmed that they often did not read much of the ACCT document prior to the ACCT review and relied more upon input of other attendees who might know the prisoner and opined their face to face assessment of the prisoner at the time. In this case, some ACCT review members had limited day to day experience of the deceased, whose temperament and presentation could change “like a light switch” and therefore face to face presentation could well be misleading. Thus in cases where the ACCT review was dealing with a particularly complex challenging prisoner and where an enhanced review was called for, it would seem appropriate for further consideration to be given to the question of review panel membership generally as well as, as above, mental health input in particular.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 mental health staff attend relevant ACCT reviews
Wider context from the report “(1) There was a clear breakdown in sharing of information known to the mental health team with other members of some ACCT reviews. Evidence was given that there has been a change in service provision contracts since the death of the deceased and that mental health staff will now work weekends. Nevertheless, it is vital that in appropriate cases where a prisoner is on an ACCT and has had substantial mental health input that they both attend relevant ACCT reviews and their opinions are given sufficient weight. It is noted that mental health nurses never chair such ACCT reviews as case manager and in this case has revealed that even in attendance, their views might not be given sufficient weight.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to share mental health information with other ACCT review members
Wider context from the report “(1) There was a clear breakdown in sharing of information known to the mental health team with other members of some ACCT reviews. Evidence was given that there has been a change in service provision contracts since the death of the deceased and that mental health staff will now work weekends. Nevertheless, it is vital that in appropriate cases where a prisoner is on an ACCT and has had substantial mental health input that they both attend relevant ACCT reviews and their opinions are given sufficient weight. It is noted that mental health nurses never chair such ACCT reviews as case manager and in this case has revealed that even in attendance, their views might not be given sufficient weight.
” 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 case managers and case-review chairs to review all relevant information before conducting ACCT case reviews.
Verbatim wording from the response “At HMP&YOI Low Newton the same staff attend ACCT reviews wherever possible. All relevant information, including developments since the last review, is discussed at the case review. This includes any information from the SystmOne record that it is appropriate for healthcare staff to share. In complex cases the enhanced case review team involves all relevant disciplines and is chaired by a higher level operational manager than a typical ACCT case review, usually the head of safer custody. In response to your report, all case managers and case review chairs have been reminded of the need to familiarise themselves with all relevant information, including the records of previous reviews and recent entries in the ACCT document, before conducting a case review.” Source location 2014-0532-Response-by-NOMS
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish mental health team input at all ACCT reviews through weekend attendance and case-manager allocation for healthcare-centre prisoners.
Verbatim wording from the response “This is primarily a matter for the healthcare provider, but I can inform you that an amended arrangement has been put in place to facilitate presence of a member of the mental health team at ACCT reviews that take place at the weekend. Effective mental health input is now ensured in all cases in which a prisoner has mental health issues: for prisoners who are located in the healthcare centre, a band 5 nurse is allocated as case manager; and for prisoners located elsewhere a member of the mental health team attends all case reviews. Briefing sessions have been introduced to facilitate the sharing of information between prison staff and the mental health team, ensuring that all staff are able to make a meaningful contribution to the decision about the level of risk.” Source location 2014-0532-Response-by-NOMS
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 briefing sessions to improve information sharing between prison staff and the mental health team during risk-level decisions.
Verbatim wording from the response “This is primarily a matter for the healthcare provider, but I can inform you that an amended arrangement has been put in place to facilitate presence of a member of the mental health team at ACCT reviews that take place at the weekend. Effective mental health input is now ensured in all cases in which a prisoner has mental health issues: for prisoners who are located in the healthcare centre, a band 5 nurse is allocated as case manager; and for prisoners located elsewhere a member of the mental health team attends all case reviews. Briefing sessions have been introduced to facilitate the sharing of information between prison staff and the mental health team, ensuring that all staff are able to make a meaningful contribution to the decision about the level of risk.” Source location 2014-0532-Response-by-NOMS
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 Information sharing is primarily the healthcare provider’s responsibility, although prison arrangements facilitate mental health participation in ACCT reviews.
Verbatim wording from the response “This is primarily a matter for the healthcare provider, but I can inform you that an amended arrangement has been put in place to facilitate presence of a member of the mental health team at ACCT reviews that take place at the weekend. Effective mental health input is now ensured in all cases in which a prisoner has mental health issues: for prisoners who are located in the healthcare centre, a band 5 nurse is allocated as case manager; and for prisoners located elsewhere a member of the mental health team attends all case reviews. Briefing sessions have been introduced to facilitate the sharing of information between prison staff and the mental health team, ensuring that all staff are able to make a meaningful contribution to the decision about the level of risk.” Source location 2014-0532-Response-by-NOMS
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 ACCT review arrangements ensure relevant information is discussed and staff familiarise themselves with prior records and recent entries.
Verbatim wording from the response “At HMP&YOI Low Newton the same staff attend ACCT reviews wherever possible. All relevant information, including developments since the last review, is discussed at the case review. This includes any information from the SystmOne record that it is appropriate for healthcare staff to share. In complex cases the enhanced case review team involves all relevant disciplines and is chaired by a higher level operational manager than a typical ACCT case review, usually the head of safer custody. In response to your report, all case managers and case review chairs have been reminded of the need to familiarise themselves with all relevant information, including the records of previous reviews and recent entries in the ACCT document, before conducting a case review.” Source location 2014-0532-Response-by-NOMS
Open published response
Concerns raised 3 Failure to adapt prison cells to individual activities-of-daily-living needs View source Failure to assign responsibility for the care and well-being of prisoners with complex needs View source Unavailability of social-services support for activities of daily living in prison 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
Barry Horrocks · 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
Barry Horrocks, who had vascular dementia and other physical and mental health problems, was serving a prison sentence at HMP Wakefield when he suffered a cerebral event and died in hospital on 5 April 2013. The principal concern was the lack of coordinated care and suitable support for his deteriorating ability to manage daily living and intimate personal care, including personal hygiene, toileting and medication.
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 adapt prison cells to individual activities-of-daily-living needs
Wider context from the report “(2) It was when in Prison that his immediate environment, that is his Prison cell was not in any way adapted to assist with activities of daily living . The ‘Social Services’ input’ which was a vital element of his care obviously could not be replicated whilst he was in prison. Such an input though was needed and necessary for his well-being.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 assign responsibility for the care and well-being of prisoners with complex needs
Wider context from the report “(3) Mr Horrocks, by virtue of his condition “fell through the net” in that none of the providers of care including health care had responsibility for a man in his condition . I was informed that assistance with intimate aspects of the activities of daily living were outside the remit of prisoner volunteers; the uniform prison officers; and those who provide primary care such as GPs and nursing staff nor, I was told, was it appropriate for him to be cared for in the Prison Healthcare Centre whether as an in-patient or out-patient. Those who provide mental health care and out of hours care did not accept any responsibility for his well-being .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 social-services support for activities of daily living in prison
Wider context from the report “(2) It was when in Prison that his immediate environment, that is his Prison cell was not in any way adapted to assist with activities of daily living. The ‘Social Services’ input’ which was a vital element of his care obviously could not be replicated whilst he was in prison . Such an input though was needed and necessary for his well-being .
” Open source report
17 Oct 2014 William Thomas Anderson · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 5 Delays in summoning emergency medical services View source Failure to record relevant inmate behaviour and presentation information in the Wing Observation Book View source Incomplete Wing staff training in the use of breathalyser equipment View source Failure to use emergency codes when required View source Inadequate vigilance over inmate social gatherings during periods of association View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
William Thomas Anderson · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
William Thomas Anderson died in his cell at HMP Wealstun on 19 September 2010 after taking prescription medication belonging to others and drinking hooch, having appeared intoxicated or under the influence of alcohol or drugs the previous afternoon. The concerns included insufficient vigilance around inmate gatherings involving drugs and alcohol, incomplete staff training and recording of observations, failure to use an emergency code, and delay in summoning paramedic assistance.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Delays in summoning emergency medical services
Wider context from the report “(5) Paramedic assistance was not called within a reasonable time and no explanation for the delay was provided in the course of the Inquest. Whilst the failure to summons outside medical assistance sooner would not have affected the outcome in this instance, it is not inconceivable that to omit to call for such assistance as soon as possible could, in certain circumstances, jeopardise an inmate’s chances of survival. Consequently, emergency services should be summoned at the very first available opportunity , and all Prison staff should be instructed as to the importance of so doing.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to record relevant inmate behaviour and presentation information in the Wing Observation Book
Wider context from the report “(3) The Deceased’s behaviour and presentation on the 18th September 2010 was not recorded by any member of Wing staff in the C Wing Observation Book . Evidence was adduced in the course of the Inquest as to the importance of recording all relevant information in the said Observation Book, thereby apprising all members of Wing staff on all shifts of all material facts and matters. In the circumstances, all relevant information in relation to, for example, an inmate’s behaviour and general presentation should be brought to the attention of all Wing staff and should be done so via an appropriate entry/entries in the Wing Observation Book . All Wing staff (Wing Managers, Prison Officers and Operational Support Grades) should be made aware of the importance of such, and should ensure information is recorded accordingly;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 Wing staff training in the use of breathalyser equipment
Wider context from the report “(2) The Deceased was not subjected to a breathalyser test at any time during the 18th September 2010. A proportion of, but not all, Wing staff are trained in the use of such breathalyser equipment . Had the Deceased been so breathalysed, more likely than not, it would have been apparent he was not suffering from the effects of alcohol. In the circumstances all Wing staff should be trained in the use of such breathalyser equipment;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 emergency codes when required
Wider context from the report “(4) The members of staff who observed the Deceased at around 5.45am on the 19th September 2010 did not “put out” a Code Blue . It was explained in the course of the Inquest that Codes Blue and Red are basic emergency codes which have been in existence for very many years. Despite the fact that, in this instance, the failure to call a Code Blue would not have affected the outcome, it is not inconceivable that to omit to use such emergency codes could, in certain circumstances, jeopardise an inmate’s chances of survival. In the circumstances, all Prison staff should be fully acquainted with the use of such codes and should use them accordingly ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 vigilance over inmate social gatherings during periods of association
Wider context from the report “(1) Evidence was adduced in the course of this Inquest to the effect that in 2010, 2011 and 2012 inmates were having social get togethers on C Wing at HMP Wealstun, in particular at a weekend, during which time drugs were taken and hooch was drunk. Evidence was also heard that this is occurring at the present time at this said prison establishment. In the circumstances, there should be much greater and effective vigilance by Wing staff and Prison Service employees at HMP Wealstun in relation to such get togethers on the Wings during periods of association ;
” Open source report
Concerns raised 1 Insufficient prison officer staffing at HMP Woodhill View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Sean Robert Brock · 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 Brock died by hanging in his prison cell at Woodhill Prison on 10 November 2013, during his fourth day in prison and his first time in an adult high-security prison. The report raised concern that a one-third reduction in prison officer numbers could compromise prison safety and put prisoner lives at 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 Insufficient prison officer staffing at HMP Woodhill
Wider context from the report “A Governor from the prison during his evidence informed me that the number of prison officers at HMP Woodhill had been reduced by one third . The reduction in numbers will in his view compromise prison safety and may put prisoner lives at risk .
” 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 Run local and national recruitment drives to address vacancies at HMP Woodhill.
Verbatim wording from the response “It is recognised that HMP Woodhill is currently experiencing a high number of vacancies across all grades. This is being addressed via local and national recruitment drives along with staff working at HMP Woodhill on detached duty.” Source location 2014-0381-Response-by-NOMS
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 Deploy staff to HMP Woodhill on detached duty to address vacancies.
Verbatim wording from the response “It is recognised that HMP Woodhill is currently experiencing a high number of vacancies across all grades. This is being addressed via local and national recruitment drives along with staff working at HMP Woodhill on detached duty.” Source location 2014-0381-Response-by-NOMS
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish an agreed staffing headcount and safe operating level for HMP Woodhill through benchmarking.
Verbatim wording from the response “You may be aware that all public sector prisons have been subject to “benchmarking” which involved a team visiting each prison and benchmarking staff-to-prisoner ratios for a wing or for a workplace. This process required establishing a safe, decent and secure operating level in agreement with the governor and the senior team. Negotiations with staff associations were also held. HMP Woodhill received its "New ways of working" report in August this year. This report set out the agreed staffing headcount.” Source location 2014-0381-Response-by-NOMS
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 designated staff for first-night procedures, prison induction and safer-custody work within the staffing forecast.
Verbatim wording from the response “HMP Woodhill is managed within the High Security estate and despite some reduction in staff numbers the current identified total staffing forecast includes an agreed complement of Officers that are necessary to provide safe decent and secure conditions. Included within the staffing forecast are staff specifically appointed to first night procedures, prison induction and safer custody work. HMP Woodhill has a Senior Manager who is responsible for safer prisons and equalities, and a Custodial Manager responsible for the management of safer custody procedures.” Source location 2014-0381-Response-by-NOMS
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 agreed staffing complement and benchmarking arrangements are considered sufficient to provide safe, decent and secure prison conditions.
Verbatim wording from the response “HMP Woodhill is managed within the High Security estate and despite some reduction in staff numbers the current identified total staffing forecast includes an agreed complement of Officers that are necessary to provide safe decent and secure conditions. Included within the staffing forecast are staff specifically appointed to first night procedures, prison induction and safer custody work. HMP Woodhill has a Senior Manager who is responsible for safer prisons and equalities, and a Custodial Manager responsible for the management of safer custody procedures.” Source location 2014-0381-Response-by-NOMS
Open published response
Concerns raised 3 Failure to ensure accurate nurse and patient signatures for recorded medication dispensing View source Unauthorised appropriation, trading and stockpiling of patient medication View source Failure to ensure medication is handed directly to the intended patient 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
Edward John Devlin · 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
Edward John Devlin was found dead in his cell at HMP Durham on 17 July 2011, having died from the effects of dihydrocodeine. The report raised concerns that medication, including potentially dangerous drugs, may have been slid under locked cell doors without confirming receipt or administration, creating risks of diversion, inaccurate medication records, stockpiling and potentially lethal overdose. It also found that his physical condition on the night before his death warranted medical assessment, but no such assessment was carried out.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure accurate nurse and patient signatures for recorded medication dispensing
Wider context from the report “(1) It was stated by a nurse that he had, while dispensing medication to Mr Devlin and other patient on F wing, slid strips of medication including dihydrocodeine under locked cell doors instead of handing it to the patient.
(2) He claimed this was his own common practice and was also common practice amongst nursing staff on F wing. This was in relation to potentially dangerous and/or tradable drugs like dihydrocodeine.
(3) If this were the case, no one would know whether a patient is taking the medication intended for him.
(4) Further, other healthcare professionals, assuming that medication was being taken by the patient, could base a future diagnosis upon this which would be potentially flawed.
(5) Assessing any other patient would become fraught with uncertainty as healthcare professionals could never know for certain what medication had been taken by him.
(6) The concomitant concern with 3, 4 and 5 above would be that the system whereby the dispensing of drugs is recorded by signatures of nurse and patient is either being ignored or subject to forgery .
(7) Further, no one would know whether somebody else was appropriating that patient’s medication.
(8) Depending on the type of medication, this may be traded within the establishment raising security concerns.
(9) The drugs could be stockpiled with a view to creating a potentially lethal overdose.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Unauthorised appropriation, trading and stockpiling of patient medication
Wider context from the report “(1) It was stated by a nurse that he had, while dispensing medication to Mr Devlin and other patient on F wing, slid strips of medication including dihydrocodeine under locked cell doors instead of handing it to the patient.
(2) He claimed this was his own common practice and was also common practice amongst nursing staff on F wing. This was in relation to potentially dangerous and/or tradable drugs like dihydrocodeine.
(3) If this were the case, no one would know whether a patient is taking the medication intended for him.
(4) Further, other healthcare professionals, assuming that medication was being taken by the patient, could base a future diagnosis upon this which would be potentially flawed.
(5) Assessing any other patient would become fraught with uncertainty as healthcare professionals could never know for certain what medication had been taken by him.
(6) The concomitant concern with 3, 4 and 5 above would be that the system whereby the dispensing of drugs is recorded by signatures of nurse and patient is either being ignored or subject to forgery.
(7) Further, no one would know whether somebody else was appropriating that patient’s medication .
(8) Depending on the type of medication, this may be traded within the establishment raising security concerns .
(9) The drugs could be stockpiled with a view to creating a potentially lethal overdose .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 medication is handed directly to the intended patient
Wider context from the report “(1) It was stated by a nurse that he had, while dispensing medication to Mr Devlin and other patient on F wing, slid strips of medication including dihydrocodeine under locked cell doors instead of handing it to the patient .
(2) He claimed this was his own common practice and was also common practice amongst nursing staff on F wing. This was in relation to potentially dangerous and/or tradable drugs like dihydrocodeine.
(3) If this were the case, no one would know whether a patient is taking the medication intended for him .
(4) Further, other healthcare professionals, assuming that medication was being taken by the patient, could base a future diagnosis upon this which would be potentially flawed.
(5) Assessing any other patient would become fraught with uncertainty as healthcare professionals could never know for certain what medication had been taken by him.
(6) The concomitant concern with 3, 4 and 5 above would be that the system whereby the dispensing of drugs is recorded by signatures of nurse and patient is either being ignored or subject to forgery.
(7) Further, no one would know whether somebody else was appropriating that patient’s medication.
(8) Depending on the type of medication, this may be traded within the establishment raising security concerns.
(9) The drugs could be stockpiled with a view to creating a potentially lethal overdose.
” Open source report
Concerns raised 12 Failure to provide detainees with the benefit and protection of a Personal Officer View source Insufficient staff understanding of vulnerable young persons’ complex needs and their causes View source Lack of a system for timely telephone contact with family during crisis or emotional need View source Night-time verbal bullying increasing self-harm and suicide risk among targeted detainees View source Unavailability of private telephone communication for detained children and young persons View source Increased risk of self-harm and suicide among vulnerable detainees with complex needs placed in Youth Offender Institutions View source Use of cells containing ligature points for detainees at risk of self-harm or suicide View source Lack of consideration of adopting safeguarding policy and procedure changes across Youth Offender Institutions View source Lack of understanding and performance oversight of Personal Officer obligations View source Insufficient staff aptitude or temperamential suitability for working with vulnerable young persons with complex needs View source Lack of a reliable system for recording and reading important wing information and outstanding tasks during Senior Officer handover View source Lack of an effective system to routinely monitor and tackle night-time verbal bullying View source See 9 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Jake Reginald Hardy · 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
Jake Reginald Hardy, a 17-year-old detained at HM YOI Hindley, died on 20 January 2012 after being found partially suspended by a ligature in his cell. The report describes failures to identify, record and respond to his vulnerabilities, self-harm risk and reports of verbal bullying, including failures in safeguarding, ACCT care planning, supervision and overnight risk assessment. Concerns also included ligature points in cells, inadequate personal officer support, staff training and communication systems, and limited access to family telephone support.
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 detainees with the benefit and protection of a Personal Officer
Wider context from the report “2. The evidence revealed an almost complete failure to provide Jake Hardy with the benefit and protection of a Personal Officer , despite a comprehensive scheme being in place. Currently the scheme is of pivotal importance for the identification and monitoring of vulnerability and risk .
There remains a concern about whether all officers at HM YOI Hindley have a sufficient understanding of this role and its importance and about the absence of any system to alert managers to any failure by a Personal Officer to meet his obligations under this scheme or to audit his performance. This concern may be of relevance to other Young Offender Institutes also.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 staff understanding of vulnerable young persons’ complex needs and their causes
Wider context from the report “1. A number of the prison staff from HM YOI Hindley who gave evidence at the inquest clearly lacked (a) any or sufficient aptitude or temperamential suitability for the demands of working with vulnerable young persons with complex needs and/or (b) any or sufficient understanding of those needs and their causes (such as the nature and effect of specific learning difficulties and the effect of abuse or neglect in childhood).
I have been told that these matters are now addressed to some extent by the Youth Justice Board and HM YOI Hindley but that further changes are being considered to the way in which prison staff working in Young Offender Institutes are recruited, screened for aptitude and trained . I report this concern so that any outstanding further steps can be 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 Lack of a system for timely telephone contact with family during crisis or emotional need
Wider context from the report “5. The children and young persons detained at HM YOI Hindley are provided with a weekly credit which they may use to telephone family or other approved numbers. Calls are made from a communal telephone located in the association area of a wing. Prison staff have a discretion to permit further calls to be made from an office telephone for good reason.
I was told that in-cell telephony has been introduced in newly built parts of the children and young persons’ estate but it is not available in HM YOI Hindley and other Young Offender Institutes. Currently, therefore, these detainees are not able to speak privately on the telephone and there is no sufficient system in place to ensure that a child or young person in crisis or in need of emotional support (whether by reason of being bullied or experiencing feelings of self-harm or suicide) can speak to a family member without significant delay.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Night-time verbal bullying increasing self-harm and suicide risk among targeted detainees
Wider context from the report “4. Verbal bullying by means of detainees “shouting out” at night is a common problem in HM YOI Hindley and can increase the risk of self-harm and suicide by those targeted , especially overnight. The fabric, lay-out and design of the cells in HM YOI Hindley does not remedy this problem. Further, it is difficult for the night orderly officer on duty on a wing, who is there alone, to tackle the problem effectively. There is no effective system in place to ensure that the problem is routinely monitored and tackled effectively, whether by means of additional staff or otherwise. This concern may be of relevance to other Young Offender Institutes also.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 private telephone communication for detained children and young persons
Wider context from the report “5. The children and young persons detained at HM YOI Hindley are provided with a weekly credit which they may use to telephone family or other approved numbers. Calls are made from a communal telephone located in the association area of a wing. Prison staff have a discretion to permit further calls to be made from an office telephone for good reason.
I was told that in-cell telephony has been introduced in newly built parts of the children and young persons’ estate but it is not available in HM YOI Hindley and other Young Offender Institutes. Currently, therefore, these detainees are not able to speak privately on the telephone and there is no sufficient system in place to ensure that a child or young person in crisis or in need of emotional support (whether by reason of being bullied or experiencing feelings of self-harm or suicide) can speak to a family member without significant delay.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Increased risk of self-harm and suicide among vulnerable detainees with complex needs placed in Youth Offender Institutions
Wider context from the report “1. It was apparent from the evidence I heard that a significant proportion of the children and young persons placed in HM YOI Hindley are vulnerable and have complex needs. This may well be true of the children and young persons placed in other Youth Offender Institutions also.
Clearly, the nature and extent of Jake Hardy’s vulnerabilities were not unusual amongst this population, with many detainees having some form of learning difficulty. I was told that other detainees are vulnerable for different reasons, for example because they have been abused or neglected or their upbringing has been adversely affected by a parent’s misuse of alcohol or drugs. Many are “looked after children”. I was also told that these detainees “complexities affect their reaction to authority and boundaries and are probably the reason they ended up in custody in the first place”.
It was also apparent that vulnerable detainees are likely to lack the emotional and intellectual maturity and resilience they may need to cope with the pressures of life in custody (such as separation from family and bullying) and that the risk of self-harm and suicide can increase in consequence. I was told that safeguarding these detainees is made more difficult by the prevalence of their volatile and unpredictable behaviour.
Overall, the evidence suggested that the placement of vulnerable children and young persons with complex needs in the environment of a Youth Offender Institute (particularly if some distance from home) does, in some cases, result in an increased risk of self-harm and suicide which it is often difficult for prison and clinical staff to manage effectively , even with the benefit of the various policies and procedures which are in place.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Use of cells containing ligature points for detainees at risk of self-harm or suicide
Wider context from the report “3. Cells containing ligature points (such as window bars) are still in use at HM YOI Hindley for detainees who have been assessed to be at risk of self-harm or suicide . This concern may be of relevance to other Young Offender Institutes also.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 consideration of adopting safeguarding policy and procedure changes across Youth Offender Institutions
Wider context from the report “2. As stated above, significant changes of policy and procedure have been introduced at HM YOI Hindley in order to address concerns raised about the identification, monitoring and protection of vulnerable children and young persons and those at risk of self-harm and suicide. It may well be that some or all of those changes would provide better protection to detainees in other Young Offender Institutes but I am not aware that consideration has been given to the adoption of these changes elsewhere in the estate .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding and performance oversight of Personal Officer obligations
Wider context from the report “2. The evidence revealed an almost complete failure to provide Jake Hardy with the benefit and protection of a Personal Officer, despite a comprehensive scheme being in place. Currently the scheme is of pivotal importance for the identification and monitoring of vulnerability and risk.
There remains a concern about whether all officers at HM YOI Hindley have a sufficient understanding of this role and its importance and about the absence of any system to alert managers to any failure by a Personal Officer to meet his obligations under this scheme or to audit his performance . This concern may be of relevance to other Young Offender Institutes also.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 staff aptitude or temperamential suitability for working with vulnerable young persons with complex needs
Wider context from the report “1. A number of the prison staff from HM YOI Hindley who gave evidence at the inquest clearly lacked (a) any or sufficient aptitude or temperamential suitability for the demands of working with vulnerable young persons with complex needs and/or (b) any or sufficient understanding of those needs and their causes (such as the nature and effect of specific learning difficulties and the effect of abuse or neglect in childhood).
I have been told that these matters are now addressed to some extent by the Youth Justice Board and HM YOI Hindley but that further changes are being considered to the way in which prison staff working in Young Offender Institutes are recruited, screened for aptitude and trained. I report this concern so that any outstanding further steps can be 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 Lack of a reliable system for recording and reading important wing information and outstanding tasks during Senior Officer handover
Wider context from the report “6. The shift patterns of Senior Officers working on the wings within HM YOI Hindley are such that they do not always overlap and handover is often by means of written entries in a “handover book”. The handover book I saw contained short notes addressing random matters and there was apparently no routine recording of a more comprehensive review of the shift. There is no system in place to ensure that important information and outstanding tasks are sufficiently recorded by one Senior Officer at the end of his shift and then read by the next Senior Officer at the start of his shift .
It was clear from the evidence that it is the Senior Officer’s responsibility to have an overview of what is happening on the wing and matters of relevance to the safeguarding of detainees housed there. Therefore, the passing of key information and outstanding tasks between Senior Officers on a wing is of real importance to the safety of detainees. This concern may be of relevance to other Young Offender Institutes also.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Lack of an effective system to routinely monitor and tackle night-time verbal bullying
Wider context from the report “4. Verbal bullying by means of detainees “shouting out” at night is a common problem in HM YOI Hindley and can increase the risk of self-harm and suicide by those targeted, especially overnight. The fabric, lay-out and design of the cells in HM YOI Hindley does not remedy this problem. Further, it is difficult for the night orderly officer on duty on a wing, who is there alone, to tackle the problem effectively. There is no effective system in place to ensure that the problem is routinely monitored and tackled effectively , whether by means of additional staff or otherwise. This concern may be of relevance to other Young Offender Institutes also.
” Open source report
Concerns raised 3 Unclear process for promptly obtaining community mental health records View source Failure to ensure ACCT health-screening doctors are trained in required procedures View source Failure to provide sufficient ACCT trigger-event recording and assessment guidance for objective risk assessment 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
Matthew Thomas Purser · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Matthew Thomas Purser hanged himself in his cell at Swansea Prison on 13 June 2012, after being remanded there and placed on self-harm monitoring. The report identified concerns about inadequate ACCT training, insufficiently objective recording and review of trigger events and significant interactions, and unclear arrangements for obtaining community mental health records.
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 Unclear process for promptly obtaining community mental health records
Wider context from the report “3. The prison appreciated that Mr. Purser was due to have a psychiatrist’s appointment in the community soon after coming into prison. Although he was booked into the primary care prison mental health service the means by which community health records were to be obtained was not clear . For an appropriate assessment to be made there is a need for an urgent contact with community mental health services to be made so that records are promptly obtained .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 ACCT health-screening doctors are trained in required procedures
Wider context from the report “1. The Doctor who saw Mr. Purser for the second health screen on the day after admission had not received ACCT training as required by PS 164/2011 and HMP Swansea Suicide Prevention Policy 2010 and was not aware of the requirement for him to be trained in the procedures .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to provide sufficient ACCT trigger-event recording and assessment guidance for objective risk assessment
Wider context from the report “2. The trigger event endorsed on the documentation requiring review of Mr. Purser under the ACCT was given as “loss of contact with partner/breakdown in relationship”. Mr. Purser’s apparent dependence on maintaining contact with his partner was correctly identified by the prison but the way in which the wording of the trigger was expressed left much to the subjective assessment of the officers about the state of his relationship with his partner. Because of the way in which the ACCT records were kept officers did not have enough information to make a realistic assessment and in their evidence some officers draw a distinction between Mr. Purser’s relationship going through a difficult time and it having broken down. If a trigger event is something which cannot be easily and objectively determined by an officer more detailed observations and recording will be required . If the only way in which a trigger can be expressed is in similar language to the trigger some indication needs to be given as to how the assessment is to be carried out and how clearly information must be shared by means of the records kept .
” Open source report
Concerns raised 2 Failure to assess the risk of suicide View source Unavailability of a suicide risk assessment tool or protocol View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Kevin Scarlett · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Kevin Scarlett was found hanging from a bunk using a sheet as a ligature in a cell at HMP Woodhill on 22 May 2013 and died. The report raised concerns that his risk of self-harm or suicide was not properly assessed and that prison and healthcare staff lacked access to a risk assessment tool or protocol. The inquest also identified concerns about his accommodation, regime, and case management.
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 assess the risk of suicide
Wider context from the report “I felt that the prison service and healthcare did not assess the risk of Mr. Scarlett taking his own life , and I was informed that the staff did not have access to a risk assessment tool or protocol for assessing such risks.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 a suicide risk assessment tool or protocol
Wider context from the report “I felt that the prison service and healthcare did not assess the risk of Mr. Scarlett taking his own life, and I was informed that the staff did not have access to a risk assessment tool or protocol for assessing such risks .
” 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 the local ACCT case-review process, including enhanced reviews for prisoners with complex needs.
Verbatim wording from the response “Turning to the circumstances leading up to Mr Scarlett’s death, NOMS accepts the findings of the PPO report and the inquest that, whilst there was an assessment of the risk of suicide or self-harm, this should have been conducted in a more rigorous manner. You may be aware that in response to the PPO’s recommendations in this case, HMP Woodhill reviewed the local ACCT process in December 2013. The case review process was revised, and guidance on this, including the use of enhanced case reviews for prisoners with complex needs, was issued to all staff (see attached staff information notice 027/14, issued in January 2014). Notices have also been issued to remind staff of known triggers and risk factors, and more recently to highlight key learning from recent deaths in custody across the prison estate (see attached staff information notice 073/14, issued in March 2014).” Source location 2014-0174-Response-by-NOMS
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 guidance and notices covering revised ACCT reviews, suicide and self-harm triggers, and learning from recent custody deaths.
Verbatim wording from the response “Turning to the circumstances leading up to Mr Scarlett’s death, NOMS accepts the findings of the PPO report and the inquest that, whilst there was an assessment of the risk of suicide or self-harm, this should have been conducted in a more rigorous manner. You may be aware that in response to the PPO’s recommendations in this case, HMP Woodhill reviewed the local ACCT process in December 2013. The case review process was revised, and guidance on this, including the use of enhanced case reviews for prisoners with complex needs, was issued to all staff (see attached staff information notice 027/14, issued in January 2014). Notices have also been issued to remind staff of known triggers and risk factors, and more recently to highlight key learning from recent deaths in custody across the prison estate (see attached staff information notice 073/14, issued in March 2014).” Source location 2014-0174-Response-by-NOMS
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 processes are considered comprehensive and effective for identifying and assessing prisoners at risk of suicide or self-harm.
Verbatim wording from the response “I hope this provides assurance that there is a comprehensive and effective set of systems for identifying that a prisoner is at risk, and that where this occurs a further detailed assessment is undertaken to ensure that all relevant factors are considered and risks identified. Some specific tools, such as the reception healthcare screen, are used, but of necessity they form only a small part of this very broad set of processes.” Source location 2014-0174-Response-by-NOMS
Open published response
Concerns raised 12 Absence of arrangements for staff use of CCTV screens View source Failure to administer prescribed medication View source Failure by healthcare professionals to attend to system 1 entries View source Inadequate communication between the Mental Health Team and Healthcare Unit staff about condition and self-harm risk View source Inadequate observation of patients in the healthcare unit View source Inadequate communication about required observation between the Mental Health In Reach Team and mental care unit staff View source Failure to correctly document information provided by mental healthcare nursing staff to Prison Officers View source Inadequate communication within the Mental Health team about condition and self-harm risk View source Infrequent observation of CCTV screens View source Failure by mental health and general nursing staff to take account of system 1 entries View source Failure to conduct post-closure interviews in accordance with ACCT policy View source Inadequate quality of CCTV images within the healthcare unit View source See 9 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Andrew Ronald Hall · 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
Andrew Ronald Hall, an inmate at HM Holme House Prison, died on 27 March 2009 after causing incised wounds to his neck in a healthcare unit cell. The concerns included inadequate communication and documentation about his mental health and self-harm risk, failures in medication administration and observation, and deficiencies in CCTV quality, monitoring and staff arrangements.
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 arrangements for staff use of CCTV screens
Wider context from the report “11. Arrangements for staff members to use the CCTV screens were absent . (Prison service & Healthcare staff)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to administer prescribed medication
Wider context from the report “8. Medication was not administered to the deceased on 23 March 2009 and 24 March 2009 as prescribed . (Medical healthcare staff)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure by healthcare professionals to attend to system 1 entries
Wider context from the report “5. Insufficient attention was paid by healthcare professionals to the system 1 entries .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Inadequate communication between the Mental Health Team and Healthcare Unit staff about condition and self-harm risk
Wider context from the report “3. There was inadequate communication between members of the Mental Health Team and the Healthcare Unit staff as to the deceased’s perceived condition and level of 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 Inadequate observation of patients in the healthcare unit
Wider context from the report “9. The deceased was not adequately observed between 6.30pm and 7.30pm on 27 March 2009. (Healthcare staff/Prison discipline 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 Inadequate communication about required observation between the Mental Health In Reach Team and mental care unit staff
Wider context from the report “4. There was inadequate communication between the Mental Health In Reach Team and the mental care unit staff as to the type and level of observation required when the deceased was re-admitted to the Healthcare Unit on 23 March 2009.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 correctly document information provided by mental healthcare nursing staff to Prison Officers
Wider context from the report “1. In the assessment of risk and risk management the jury found (inter alia) information provided by mental healthcare nursing staff to Prison Officers was not correctly documented .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Inadequate communication within the Mental Health team about condition and self-harm risk
Wider context from the report “2. There was inadequate communication between members of the Mental Health team as to the deceased’s condition and the level of 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 Infrequent observation of CCTV screens
Wider context from the report “12. There was infrequent observation of the CCTV screens on 27 March 2009. (Prison service & Healthcare staff)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure by mental health and general nursing staff to take account of system 1 entries
Wider context from the report “6. That both mental health staff and general nursing staff inadequately took into account the entry made by ████████
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 post-closure interviews in accordance with ACCT policy
Wider context from the report “7. That a post-closure interview in accordance with the (then) ACCT policy should have been conducted . (Prison staff, healthcare staff and Mental Health team)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Inadequate quality of CCTV images within the healthcare unit
Wider context from the report “10. The quality of CCTV images within the healthcare unit was inadequate . ( prison service)
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct an additional ACCT post-closure review after one month.
Verbatim wording from the response “You are concerned that a post-closure review of the ACCT was not conducted (point 7). A system is now in place within the safer custody department to ensure that all post-closure reviews take place within the seven day period mandated in Prison Service Instruction (PSI) 64/2011 Safer Custody. A local policy that an additional post-closure review is conducted after one month has been introduced.” Source location 2014-0122-Response-by-NOMS
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 Ensure all ACCT post-closure reviews occur within the mandated seven-day period.
Verbatim wording from the response “You are concerned that a post-closure review of the ACCT was not conducted (point 7). A system is now in place within the safer custody department to ensure that all post-closure reviews take place within the seven day period mandated in Prison Service Instruction (PSI) 64/2011 Safer Custody. A local policy that an additional post-closure review is conducted after one month has been introduced.” Source location 2014-0122-Response-by-NOMS
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Record mental health risk information received during ACCT reviews and monitor that contributions are documented.
Verbatim wording from the response “You are concerned that information about risk provided by mental healthcare nursing staff to prison staff was not correctly documented (point 1). ACCT reviews are chaired by supervising officers who record any information about risk that is received from the mental health team. Where a prisoner has mental health issues, a member of the mental health team is invited to attend all ACCT reviews. The mental health team has received ACCT training, and further training sessions are arranged when new members join the team. Mental health staff play an active role in the management of ACCT plans, and a significant number of ACCTs are opened by the team. The prison’s regular management checks confirm that members of the mental health team attend reviews and that their contributions are recorded.” Source location 2014-0122-Response-by-NOMS
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remove CCTV cameras from healthcare-unit cells and use constant-observation cells with constant supervision for prisoners requiring high observation.
Verbatim wording from the response “You raise a number of concerns about the effectiveness of the arrangements to observe prisoners in cells in the healthcare unit using CCTV (points 9-12, 15 and 16). Cameras have been removed from all cells and any prisoner assessed as requiring high levels of observation is located in a constant observation cell and subject to constant supervision in accordance with the arrangements set out in chapter 6 of PSI 64/2011.” Source location 2014-0122-Response-by-NOMS
Open published response
Concerns raised 4 Failure to complete escort handover details on the PER View source Failure to ensure that police documentation recorded as accompanying the PER is available to escort staff View source Lack of shared understanding about police documentation accompanying persons in custody View source Failure to complete and provide the police risk assessment before custody escort View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Lee Sean MACPHERSON · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Lee Sean MACPHERSON was found dead in a safer custody cell at HMP Wormwood Scrubs on 17 October 2012, after being remanded into custody the previous afternoon. Concerns related to incomplete and inconsistently transferred police risk-assessment and escort handover documentation between the police, SERCO and 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 complete escort handover details on the PER
Wider context from the report “(3) The escort handover details on the PER were not completed by the prison staff (or SERCO staff which is a matter SERCO have already addressed).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure that police documentation recorded as accompanying the PER is available to escort staff
Wider context from the report “(2) There was a lack of common understanding between SERCO staff and prison staff about what police documentation, including the police risk assessment, accompanied a person in custody, in addition to the PER. Boxes on the PER had been ticked indicating that, among other things, it was accompanied by a police risk assessment but SERCO staff said they had not seen that or the other documents .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 shared understanding about police documentation accompanying persons in custody
Wider context from the report “(2) There was a lack of common understanding between SERCO staff and prison staff about what police documentation, including the police risk assessment, accompanied a person in custody, in addition to the PER. Boxes on the PER had been ticked indicating that, among other things, it was accompanied by a police risk assessment but SERCO staff said they had not seen that or the other documents .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to complete and provide the police risk assessment before custody escort
Wider context from the report “(1) The police risk assessment was not completed until the deceased had already been collected by SERCO and it was a police risk assessment completed in the early hours of the morning that found its way to the prison .
” Open source report
Concerns raised 6 Failure to fully investigate prisoners’ reported episodes of loss of consciousness View source Failure to conduct NICE-compliant investigations of loss of consciousness View source Failure to make accurate and evidentially grounded entries in prisoners’ medical notes View source Failure to conduct clinical investigations of prisoners experiencing loss of consciousness View source Failure to take full account of family history when clinically investigating prisoners with possible high cholesterol View source Lack of doctors’ awareness of NICE guidelines for transient loss of consciousness View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Lee Terence Curran · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Lee Terence Curran died on 3 May 2011 while in custody at Forest Bank Prison, with naturally occurring ischaemic heart disease identified as the prime cause of death. Before his death, he experienced multiple episodes of transient loss of consciousness that were not diagnosed, and concerns were raised that recommended investigations and follow-up were not provided. Further concerns included incomplete implementation of recommendations, potentially misleading medical-note entries, and inadequate awareness or application of relevant clinical guidelines.
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 investigate prisoners’ reported episodes of loss of consciousness
Wider context from the report “(3) Evidence given at the Inquest also revealed a need for the training of Doctors working in prisons in that Doctors who provided general practice sessions at the prison (and in the community) gave evidence that they were unaware of the NICE Guidelines for Transient Loss of Consciousness Management in Adults and Young People despite such episodes being common in a prison environment. Additionally evidence was given by a Doctor that efforts were not made to fully investigate Lee Terence Curran’s episodes of loss of consciousness because, the Doctor explained, it was common for prisoners to claim to have suffered losses of consciousness as a form of drug seeking behaviour .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct NICE-compliant investigations of loss of consciousness
Wider context from the report “(1) The Prisons and Probation Ombudsman investigated Lee Terence Curran’s death. At the conclusion of that investigation certain recommendations were made, two of which were as follows:
a. “The Head of Healthcare should ensure that healthcare staff take full account of family history when arranging clinical investigations for prisoners who report, or are observed to have possible signs of high cholesterol or hypertension”.
b. “The Head of Healthcare should develop a protocol that is NICE compliant for investigating episodes of loss of consciousness and should ensure that staff conduct clinical investigations of prisoners who experience such episodes.”
Both of these recommendations were accepted. However the evidence given at the Inquest in relation to the implementation of recommendation a. was that all prisoners coming to Forest Bank Prison undertake the reception screening process and any prisoner with any identified, or any sign of, hypertension is referred to the hypertension clinic. A full account of the prisoner’s family history is then taken at that clinic. There was no evidence that any action had been taken to address that part of the Ombudsman’s recommendation that related to prisoners (such as Lee Terence Curran) who reported or showed signs of having high cholesterol.
Likewise with recommendation b. The evidence given at the Inquest with regard to the implementation of that recommendation was that any individual who had a loss of consciousness would be automatically referred to a Doctor. That action does not encompass the whole of the Ombudsman’s recommendation. Particularly it does not ensure that investigations of episodes of loss of consciousness are NICE compliant nor does it ensure that staff conduct clinical investigations of prisoners who experience such episodes. It should be remembered here that Doctors saw Lee Terence Curran on five occasions following episodes of loss of consciousness and the NICE guidelines were not followed at any time .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to make accurate and evidentially grounded entries in prisoners’ medical notes
Wider context from the report “(2) Evidence given at the Inquest revealed a potential need for the training of Prison staff as to the manner in which they make entries in prisoners’ medical notes. Expressly, incorrect, and potentially misleading, information had been entered in Lee Terence Curran’s medical notes concerning the episodes of loss of consciousness that he experienced. For example a nurse described one such episode as a “petit mal seizure,” whilst evidence at the Inquest made it clear that such could not have been the case. In addition those attending information did not make the basis upon which they were entering that information clear, that is they entered information that indicated that they had witnessed an event when they had not .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 clinical investigations of prisoners experiencing loss of consciousness
Wider context from the report “(1) The Prisons and Probation Ombudsman investigated Lee Terence Curran’s death. At the conclusion of that investigation certain recommendations were made, two of which were as follows:
a. “The Head of Healthcare should ensure that healthcare staff take full account of family history when arranging clinical investigations for prisoners who report, or are observed to have possible signs of high cholesterol or hypertension”.
b. “The Head of Healthcare should develop a protocol that is NICE compliant for investigating episodes of loss of consciousness and should ensure that staff conduct clinical investigations of prisoners who experience such episodes.”
Both of these recommendations were accepted. However the evidence given at the Inquest in relation to the implementation of recommendation a. was that all prisoners coming to Forest Bank Prison undertake the reception screening process and any prisoner with any identified, or any sign of, hypertension is referred to the hypertension clinic. A full account of the prisoner’s family history is then taken at that clinic. There was no evidence that any action had been taken to address that part of the Ombudsman’s recommendation that related to prisoners (such as Lee Terence Curran) who reported or showed signs of having high cholesterol.
Likewise with recommendation b. The evidence given at the Inquest with regard to the implementation of that recommendation was that any individual who had a loss of consciousness would be automatically referred to a Doctor. That action does not encompass the whole of the Ombudsman’s recommendation. Particularly it does not ensure that investigations of episodes of loss of consciousness are NICE compliant nor does it ensure that staff conduct clinical investigations of prisoners who experience such episodes . It should be remembered here that Doctors saw Lee Terence Curran on five occasions following episodes of loss of consciousness and the NICE guidelines were not followed at any time.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 take full account of family history when clinically investigating prisoners with possible high cholesterol
Wider context from the report “(1) The Prisons and Probation Ombudsman investigated Lee Terence Curran’s death. At the conclusion of that investigation certain recommendations were made, two of which were as follows:
a. “The Head of Healthcare should ensure that healthcare staff take full account of family history when arranging clinical investigations for prisoners who report, or are observed to have possible signs of high cholesterol or hypertension”.
b. “The Head of Healthcare should develop a protocol that is NICE compliant for investigating episodes of loss of consciousness and should ensure that staff conduct clinical investigations of prisoners who experience such episodes.”
Both of these recommendations were accepted. However the evidence given at the Inquest in relation to the implementation of recommendation a. was that all prisoners coming to Forest Bank Prison undertake the reception screening process and any prisoner with any identified, or any sign of, hypertension is referred to the hypertension clinic. A full account of the prisoner’s family history is then taken at that clinic. There was no evidence that any action had been taken to address that part of the Ombudsman’s recommendation that related to prisoners (such as Lee Terence Curran) who reported or showed signs of having high cholesterol.
Likewise with recommendation b. The evidence given at the Inquest with regard to the implementation of that recommendation was that any individual who had a loss of consciousness would be automatically referred to a Doctor. That action does not encompass the whole of the Ombudsman’s recommendation. Particularly it does not ensure that investigations of episodes of loss of consciousness are NICE compliant nor does it ensure that staff conduct clinical investigations of prisoners who experience such episodes. It should be remembered here that Doctors saw Lee Terence Curran on five occasions following episodes of loss of consciousness and the NICE guidelines were not followed at any time.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 doctors’ awareness of NICE guidelines for transient loss of consciousness
Wider context from the report “(3) Evidence given at the Inquest also revealed a need for the training of Doctors working in prisons in that Doctors who provided general practice sessions at the prison (and in the community) gave evidence that they were unaware of the NICE Guidelines for Transient Loss of Consciousness Management in Adults and Young People despite such episodes being common in a prison environment . Additionally evidence was given by a Doctor that efforts were not made to fully investigate Lee Terence Curran’s episodes of loss of consciousness because, the Doctor explained, it was common for prisoners to claim to have suffered losses of consciousness as a form of drug seeking behaviour.
” Open source report
Concerns raised 4 Failure of the Personal Officer Scheme to operate effectively for trainees View source Failure to conduct ACCT checks at the times prescribed by the trainee's ACCT document View source Failure of Prison Officers to follow the correct procedure for roll counts of trainees View source Insufficient Prison Officer competence and refresher training in first aid and CPR 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
Ryan Patrick John Clark · 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
Ryan Patrick John Clark, aged 17, died on 18 April 2011 after being discovered in his cell at HMYOI Wetherby with a ligature around his neck; his death was certified at Harrogate District Hospital. The concerns included ineffective implementation of the Personal Officer Scheme, failures in ACCT checks and trainee roll counts, and insufficient first-aid and CPR training for prison officers.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure of the Personal Officer Scheme to operate effectively for trainees
Wider context from the report “At HMYOI Wetherby
(1) The Personal Officer Scheme was not properly implemented and did not operate effectively vis a vis trainees ;
(2) ACCT checks of a trainee were not made and/or were not made in accordance with the times prescribed by the trainee's ACCT document;
(3) The correct procedure when conducting a roll count of trainees was not adopted by Prison Officers;
(4) Prison Officers were not fully conversant in the administration of first aid and CPR and had not received regular refresher training in relation thereto.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 ACCT checks at the times prescribed by the trainee's ACCT document
Wider context from the report “At HMYOI Wetherby
(1) The Personal Officer Scheme was not properly implemented and did not operate effectively vis a vis trainees;
(2) ACCT checks of a trainee were not made and/or were not made in accordance with the times prescribed by the trainee's ACCT document ;
(3) The correct procedure when conducting a roll count of trainees was not adopted by Prison Officers;
(4) Prison Officers were not fully conversant in the administration of first aid and CPR and had not received regular refresher training in relation thereto.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 Officers to follow the correct procedure for roll counts of trainees
Wider context from the report “At HMYOI Wetherby
(1) The Personal Officer Scheme was not properly implemented and did not operate effectively vis a vis trainees;
(2) ACCT checks of a trainee were not made and/or were not made in accordance with the times prescribed by the trainee's ACCT document;
(3) The correct procedure when conducting a roll count of trainees was not adopted by Prison Officers ;
(4) Prison Officers were not fully conversant in the administration of first aid and CPR and had not received regular refresher training in relation thereto.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 Officer competence and refresher training in first aid and CPR
Wider context from the report “At HMYOI Wetherby
(1) The Personal Officer Scheme was not properly implemented and did not operate effectively vis a vis trainees;
(2) ACCT checks of a trainee were not made and/or were not made in accordance with the times prescribed by the trainee's ACCT document;
(3) The correct procedure when conducting a roll count of trainees was not adopted by Prison Officers;
(4) Prison Officers were not fully conversant in the administration of first aid and CPR and had not received regular refresher training in relation thereto .
” 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 Brief all staff on the importance of conducting roll checks.
Verbatim wording from the response “Roll Checks
The two failures to follow the procedure for roll checks identified in this case have been the subject of investigations, and disciplinary action has been taken against the staff involved. All staff have been briefed on the importance of roll checks, and these are now subject to covert checks by managers. If, following a cover check, there is any doubt as to whether or not a proper roll check was carried out, CCTV evidence is examined, and a disciplinary investigation is instigated where necessary.” Source location 2014-0057-Response-by-NOMS
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 additional management-check layer for all ACCT documents.
Verbatim wording from the response “ACCT Checks
The Governor is confident that the failure of one officer to conduct an ACCT check on one occasion is not representative of practice among staff at HMP and YOI Wetherby, and the incident in question was the subject of a disciplinary investigation. Staff are now briefed on the timings of ACCT checks and the need for good quality interactions and observations at the start of each shift. In addition, full ACCT guidance has been reissued, and priority is being given to providing ACCT refresher training for all staff. In order to provide further reassurance, the Governor has introduced an additional layer of management checks of all ACCT documents.” Source location 2014-0057-Response-by-NOMS
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 full ACCT guidance to staff.
Verbatim wording from the response “ACCT Checks
The Governor is confident that the failure of one officer to conduct an ACCT check on one occasion is not representative of practice among staff at HMP and YOI Wetherby, and the incident in question was the subject of a disciplinary investigation. Staff are now briefed on the timings of ACCT checks and the need for good quality interactions and observations at the start of each shift. In addition, full ACCT guidance has been reissued, and priority is being given to providing ACCT refresher training for all staff. In order to provide further reassurance, the Governor has introduced an additional layer of management checks of all ACCT documents.” Source location 2014-0057-Response-by-NOMS
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Brief staff on ACCT check timings, quality interactions and observations at the start of each shift.
Verbatim wording from the response “ACCT Checks
The Governor is confident that the failure of one officer to conduct an ACCT check on one occasion is not representative of practice among staff at HMP and YOI Wetherby, and the incident in question was the subject of a disciplinary investigation. Staff are now briefed on the timings of ACCT checks and the need for good quality interactions and observations at the start of each shift. In addition, full ACCT guidance has been reissued, and priority is being given to providing ACCT refresher training for all staff. In order to provide further reassurance, the Governor has introduced an additional layer of management checks of all ACCT documents.” Source location 2014-0057-Response-by-NOMS
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 covert managerial checks of roll checks.
Verbatim wording from the response “Roll Checks
The two failures to follow the procedure for roll checks identified in this case have been the subject of investigations, and disciplinary action has been taken against the staff involved. All staff have been briefed on the importance of roll checks, and these are now subject to covert checks by managers. If, following a cover check, there is any doubt as to whether or not a proper roll check was carried out, CCTV evidence is examined, and a disciplinary investigation is instigated where necessary.” Source location 2014-0057-Response-by-NOMS
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Train all custodial managers in First Aid at Work and operational support night-patrol staff in Emergency First Aid at Work.
Verbatim wording from the response “First Aid and CPR
PSI 01/2014 First Aid describes the process for ensuring effective provision of first aid that enables NOMS to discharge its duty of care to its employees, to prisoners and to visitors to our premises. Governors are required to ensure that at all times such numbers of suitably trained first aiders as is sufficient and appropriate for the circumstances are available. A First Aid risk/needs assessment is undertaken by the local Health and Safety Advisor to determine the appropriate numbers. Governors must ensure that first aiders are trained to levels which are appropriate for the circumstances and hold a valid certificate of competence in either First Aid at Work (FAW) or Emergency First Aid at Work (EFAW).” Source location 2014-0057-Response-by-NOMS
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 personal officer scheme with staff continuity, relief cover and supportive-role briefing.
Verbatim wording from the response “In October 2013 HMP and YOI Wetherby implemented a revised personal officer scheme that aims to ensure greater continuity in the allocation of staff to young people and includes a ‘relief’ arrangement whereby a paired officer is available to cover during the periods of absence that are inevitable with staff working shifts. The new scheme emphasises the” Source location 2014-0057-Response-by-NOMS
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 ACCT refresher training for all staff.
Verbatim wording from the response “ACCT Checks
The Governor is confident that the failure of one officer to conduct an ACCT check on one occasion is not representative of practice among staff at HMP and YOI Wetherby, and the incident in question was the subject of a disciplinary investigation. Staff are now briefed on the timings of ACCT checks and the need for good quality interactions and observations at the start of each shift. In addition, full ACCT guidance has been reissued, and priority is being given to providing ACCT refresher training for all staff. In order to provide further reassurance, the Governor has introduced an additional layer of management checks of all ACCT documents.” Source location 2014-0057-Response-by-NOMS
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 isolated ACCT check failure is not representative of practice at HMP and YOI Wetherby.
Verbatim wording from the response “ACCT Checks
The Governor is confident that the failure of one officer to conduct an ACCT check on one occasion is not representative of practice among staff at HMP and YOI Wetherby, and the incident in question was the subject of a disciplinary investigation. Staff are now briefed on the timings of ACCT checks and the need for good quality interactions and observations at the start of each shift. In addition, full ACCT guidance has been reissued, and priority is being given to providing ACCT refresher training for all staff. In order to provide further reassurance, the Governor has introduced an additional layer of management checks of all ACCT documents.” Source location 2014-0057-Response-by-NOMS
Open published response
Concerns raised 12 Failure to secure mutual aid for bed watch cover View source Lack of clarity about responsibility for funding and payment of privately funded care and transfers View source Lack of clarity about the circumstances and means for arranging hospital transfers View source Unavailability of scales in all medical consulting rooms View source Lack of a system guiding privately funded transfers between hospitals View source Failure of medical records to clearly record information availability, entry timing and authorship View source Failure of doctors and nurses to routinely weigh patients View source Lack of designated ownership and control for complex hospital transfer arrangements View source Lack of policy or guidance for prison staff and health care providers managing complex privately funded transfers View source Delays and limitations in liaison and communication between prison and hospital health care staff View source Lack of clarity in rules governing prisoners’ entitlement to private health care View source Lack of a formal policy for situations involving privately funded prisoner health care and hospital transfers View source See 9 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Zeeyad Hamadi · 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
Zeeyad Hamadi was a prisoner at HMP Frankland who became unwell, was diagnosed with Hodgkins Lymphoma, and deteriorated while arrangements were made to transfer him to a London hospital for private chemotherapy. Concerns included inadequate weighing and medical record keeping, limited communication between prison and hospital staff, unclear funding and transfer arrangements, and the absence of a system or responsible point of contact to manage the transfer, contributing to delay.
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 secure mutual aid for bed watch cover
Wider context from the report “(4) Requests by HMP Frankland for mutual aid from prisons in London to provide bed watch office cover were unsuccessful and it was only after the intervention of the governing Governor of HMP Frankland with a senior manager at the high security estate Headquarters of the prison service that an instruction was given for a London prison to provide bed watch cover. There was a lack of understanding as to and what circumstances the transfer from Durham to London could be facilitated by an NHS ambulance, a private ambulance or an air ambulance. There was no evidence to show bad faith on the part of any of the individuals who were involved in this transfer process but there was no system in place to aid those involved in this process to guide them as to how a transfer should properly be made from an NHS hospital in one part of the country to a hospital in another part of the country where treatment was to be privately funded. There was as a result no single point of contact within the prison (either of a health care or a discipline background) who was able to take ownership of the issue, or a group of people properly designated to take control of such a situation, with the result that in conjunction with the failure for mutual aid to be given the bed watch requirements for a delay to have taken place which could have reduced the deceased’s chances of receiving treatment which may have prolonged his life. Evidence was given that notwithstanding the fact that the deceased died in October 2010 no policy or guidance has been introduced to assist either prison service staff or health care providers with the issues highlighted by this case which were described in evidence as unprecedented.
Although there may be limited occasions when prisoners might have family resources to provide private medical care it is possible that more people will have the benefit of private medical insurance which may be of assistance in similar cases. The use of such private medical care covered by insurance would lead to a reduction in the cost burden imposed on the NHS.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 clarity about responsibility for funding and payment of privately funded care and transfers
Wider context from the report “(3) There was limited liaison between health care staff in HMP Frankland and medical staff at UHND to monitor the deceased’s medical condition once he had left the prison. When a decision was made by the deceased to seek treatment in London on a private paying basis this information was not speedily communicated to those responsible for health care in HMP Frankland and contact was made by a hospital doctor with a duty governor at the prison who in turn had to refer to the health care manager. Confusion developed as to the basis of the proposed move to Bart’s from UHND; whether this was a prison to prison transfer or whether it was a relocation of the deceased from one hospital to another whilst remaining the responsibility of HMP Frankland. There was confusion over the funding arrangements for this proposal; whether the local NHS would be responsible for the medical treatment or the costs of transport, the form of such transport and/or the costs of bed watch. The brother of the deceased confirmed to different people at different times that he would undertake to be responsible for the costs incurred (subject to a challenge by Judicial review) and it took some time for the issues of funding to be identified before being addressed and resolved. There was a lack of clarity of understanding who would be responsible for what and when, so far as money was concerned and who would have the responsibility for payment in the first place prior to reimbursement by the deceased’s brother . There was no formal policy in place to deal with the situation. There was lack of clarity in the rules that were referred to in evidence as to how and when a convicted prisoner is entitled to private health care as opposed to a prisoner on remand.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about the circumstances and means for arranging hospital transfers
Wider context from the report “(4) Requests by HMP Frankland for mutual aid from prisons in London to provide bed watch office cover were unsuccessful and it was only after the intervention of the governing Governor of HMP Frankland with a senior manager at the high security estate Headquarters of the prison service that an instruction was given for a London prison to provide bed watch cover. There was a lack of understanding as to and what circumstances the transfer from Durham to London could be facilitated by an NHS ambulance, a private ambulance or an air ambulance . There was no evidence to show bad faith on the part of any of the individuals who were involved in this transfer process but there was no system in place to aid those involved in this process to guide them as to how a transfer should properly be made from an NHS hospital in one part of the country to a hospital in another part of the country where treatment was to be privately funded. There was as a result no single point of contact within the prison (either of a health care or a discipline background) who was able to take ownership of the issue, or a group of people properly designated to take control of such a situation, with the result that in conjunction with the failure for mutual aid to be given the bed watch requirements for a delay to have taken place which could have reduced the deceased’s chances of receiving treatment which may have prolonged his life. Evidence was given that notwithstanding the fact that the deceased died in October 2010 no policy or guidance has been introduced to assist either prison service staff or health care providers with the issues highlighted by this case which were described in evidence as unprecedented.
Although there may be limited occasions when prisoners might have family resources to provide private medical care it is possible that more people will have the benefit of private medical insurance which may be of assistance in similar cases. The use of such private medical care covered by insurance would lead to a reduction in the cost burden imposed on the NHS.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 scales in all medical consulting rooms
Wider context from the report “(1) The evidence disclosed that the deceased had not been weighed at the times of medical appointments and a history of weight loss would have been a useful diagnostic tool. Not all medical consulting rooms at HMP Frankland had scales to do so and doctors/nurses did not routinely weigh patients.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 system guiding privately funded transfers between hospitals
Wider context from the report “(4) Requests by HMP Frankland for mutual aid from prisons in London to provide bed watch office cover were unsuccessful and it was only after the intervention of the governing Governor of HMP Frankland with a senior manager at the high security estate Headquarters of the prison service that an instruction was given for a London prison to provide bed watch cover. There was a lack of understanding as to and what circumstances the transfer from Durham to London could be facilitated by an NHS ambulance, a private ambulance or an air ambulance. There was no evidence to show bad faith on the part of any of the individuals who were involved in this transfer process but there was no system in place to aid those involved in this process to guide them as to how a transfer should properly be made from an NHS hospital in one part of the country to a hospital in another part of the country where treatment was to be privately funded . There was as a result no single point of contact within the prison (either of a health care or a discipline background) who was able to take ownership of the issue, or a group of people properly designated to take control of such a situation, with the result that in conjunction with the failure for mutual aid to be given the bed watch requirements for a delay to have taken place which could have reduced the deceased’s chances of receiving treatment which may have prolonged his life. Evidence was given that notwithstanding the fact that the deceased died in October 2010 no policy or guidance has been introduced to assist either prison service staff or health care providers with the issues highlighted by this case which were described in evidence as unprecedented.
Although there may be limited occasions when prisoners might have family resources to provide private medical care it is possible that more people will have the benefit of private medical insurance which may be of assistance in similar cases. The use of such private medical care covered by insurance would lead to a reduction in the cost burden imposed on the NHS.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 medical records to clearly record information availability, entry timing and authorship
Wider context from the report “(2) It was accepted in evidence that the standard of record keeping in the patient’s medical notes was not as good as it could or should have been . There was lack of clarity as to when certain medical information (for example blood tests results) were available for interpretation by a doctor , by paper or electronic means, there was lack of clarity as from the computer printouts of medical records when entries were inputted into the system and were available for view, who was the author of the entry (as opposed to who inputted the data) .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 doctors and nurses to routinely weigh patients
Wider context from the report “(1) The evidence disclosed that the deceased had not been weighed at the times of medical appointments and a history of weight loss would have been a useful diagnostic tool. Not all medical consulting rooms at HMP Frankland had scales to do so and doctors/nurses did not routinely weigh patients .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 designated ownership and control for complex hospital transfer arrangements
Wider context from the report “(4) Requests by HMP Frankland for mutual aid from prisons in London to provide bed watch office cover were unsuccessful and it was only after the intervention of the governing Governor of HMP Frankland with a senior manager at the high security estate Headquarters of the prison service that an instruction was given for a London prison to provide bed watch cover. There was a lack of understanding as to and what circumstances the transfer from Durham to London could be facilitated by an NHS ambulance, a private ambulance or an air ambulance. There was no evidence to show bad faith on the part of any of the individuals who were involved in this transfer process but there was no system in place to aid those involved in this process to guide them as to how a transfer should properly be made from an NHS hospital in one part of the country to a hospital in another part of the country where treatment was to be privately funded. There was as a result no single point of contact within the prison (either of a health care or a discipline background) who was able to take ownership of the issue, or a group of people properly designated to take control of such a situation, with the result that in conjunction with the failure for mutual aid to be given the bed watch requirements for a delay to have taken place which could have reduced the deceased’s chances of receiving treatment which may have prolonged his life. Evidence was given that notwithstanding the fact that the deceased died in October 2010 no policy or guidance has been introduced to assist either prison service staff or health care providers with the issues highlighted by this case which were described in evidence as unprecedented.
Although there may be limited occasions when prisoners might have family resources to provide private medical care it is possible that more people will have the benefit of private medical insurance which may be of assistance in similar cases. The use of such private medical care covered by insurance would lead to a reduction in the cost burden imposed on the NHS.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Lack of policy or guidance for prison staff and health care providers managing complex privately funded transfers
Wider context from the report “(4) Requests by HMP Frankland for mutual aid from prisons in London to provide bed watch office cover were unsuccessful and it was only after the intervention of the governing Governor of HMP Frankland with a senior manager at the high security estate Headquarters of the prison service that an instruction was given for a London prison to provide bed watch cover. There was a lack of understanding as to and what circumstances the transfer from Durham to London could be facilitated by an NHS ambulance, a private ambulance or an air ambulance. There was no evidence to show bad faith on the part of any of the individuals who were involved in this transfer process but there was no system in place to aid those involved in this process to guide them as to how a transfer should properly be made from an NHS hospital in one part of the country to a hospital in another part of the country where treatment was to be privately funded. There was as a result no single point of contact within the prison (either of a health care or a discipline background) who was able to take ownership of the issue, or a group of people properly designated to take control of such a situation, with the result that in conjunction with the failure for mutual aid to be given the bed watch requirements for a delay to have taken place which could have reduced the deceased’s chances of receiving treatment which may have prolonged his life. Evidence was given that notwithstanding the fact that the deceased died in October 2010 no policy or guidance has been introduced to assist either prison service staff or health care providers with the issues highlighted by this case which were described in evidence as unprecedented.
Although there may be limited occasions when prisoners might have family resources to provide private medical care it is possible that more people will have the benefit of private medical insurance which may be of assistance in similar cases. The use of such private medical care covered by insurance would lead to a reduction in the cost burden imposed on the NHS.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 limitations in liaison and communication between prison and hospital health care staff
Wider context from the report “(3) There was limited liaison between health care staff in HMP Frankland and medical staff at UHND to monitor the deceased’s medical condition once he had left the prison . When a decision was made by the deceased to seek treatment in London on a private paying basis this information was not speedily communicated to those responsible for health care in HMP Frankland and contact was made by a hospital doctor with a duty governor at the prison who in turn had to refer to the health care manager. Confusion developed as to the basis of the proposed move to Bart’s from UHND; whether this was a prison to prison transfer or whether it was a relocation of the deceased from one hospital to another whilst remaining the responsibility of HMP Frankland. There was confusion over the funding arrangements for this proposal; whether the local NHS would be responsible for the medical treatment or the costs of transport, the form of such transport and/or the costs of bed watch. The brother of the deceased confirmed to different people at different times that he would undertake to be responsible for the costs incurred (subject to a challenge by Judicial review) and it took some time for the issues of funding to be identified before being addressed and resolved. There was a lack of clarity of understanding who would be responsible for what and when, so far as money was concerned and who would have the responsibility for payment in the first place prior to reimbursement by the deceased’s brother. There was no formal policy in place to deal with the situation. There was lack of clarity in the rules that were referred to in evidence as to how and when a convicted prisoner is entitled to private health care as opposed to a prisoner on remand.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity in rules governing prisoners’ entitlement to private health care
Wider context from the report “(3) There was limited liaison between health care staff in HMP Frankland and medical staff at UHND to monitor the deceased’s medical condition once he had left the prison. When a decision was made by the deceased to seek treatment in London on a private paying basis this information was not speedily communicated to those responsible for health care in HMP Frankland and contact was made by a hospital doctor with a duty governor at the prison who in turn had to refer to the health care manager. Confusion developed as to the basis of the proposed move to Bart’s from UHND; whether this was a prison to prison transfer or whether it was a relocation of the deceased from one hospital to another whilst remaining the responsibility of HMP Frankland. There was confusion over the funding arrangements for this proposal; whether the local NHS would be responsible for the medical treatment or the costs of transport, the form of such transport and/or the costs of bed watch. The brother of the deceased confirmed to different people at different times that he would undertake to be responsible for the costs incurred (subject to a challenge by Judicial review) and it took some time for the issues of funding to be identified before being addressed and resolved. There was a lack of clarity of understanding who would be responsible for what and when, so far as money was concerned and who would have the responsibility for payment in the first place prior to reimbursement by the deceased’s brother. There was no formal policy in place to deal with the situation. There was lack of clarity in the rules that were referred to in evidence as to how and when a convicted prisoner is entitled to private health care as opposed to a prisoner on remand .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Lack of a formal policy for situations involving privately funded prisoner health care and hospital transfers
Wider context from the report “(3) There was limited liaison between health care staff in HMP Frankland and medical staff at UHND to monitor the deceased’s medical condition once he had left the prison. When a decision was made by the deceased to seek treatment in London on a private paying basis this information was not speedily communicated to those responsible for health care in HMP Frankland and contact was made by a hospital doctor with a duty governor at the prison who in turn had to refer to the health care manager. Confusion developed as to the basis of the proposed move to Bart’s from UHND; whether this was a prison to prison transfer or whether it was a relocation of the deceased from one hospital to another whilst remaining the responsibility of HMP Frankland. There was confusion over the funding arrangements for this proposal; whether the local NHS would be responsible for the medical treatment or the costs of transport, the form of such transport and/or the costs of bed watch. The brother of the deceased confirmed to different people at different times that he would undertake to be responsible for the costs incurred (subject to a challenge by Judicial review) and it took some time for the issues of funding to be identified before being addressed and resolved. There was a lack of clarity of understanding who would be responsible for what and when, so far as money was concerned and who would have the responsibility for payment in the first place prior to reimbursement by the deceased’s brother. There was no formal policy in place to deal with the situation . There was lack of clarity in the rules that were referred to in evidence as to how and when a convicted prisoner is entitled to private health care as opposed to a prisoner on remand.
” Open source report
Concerns raised 10 Failure to secure complete health care information for ACCT reviews View source Lack of health care staff training to manage tobacco withdrawal View source Inconsistent requests for members to attend ACCT reviews View source Failure to establish individual learning from ACCT review involvement View source Unclear responsibility for tobacco-withdrawal screening and management View source Failure to ensure fully informed decisions on reducing observations for vulnerable prisoners in the Segregation Unit View source Lack of health care staff training to conduct tobacco-withdrawal screening View source Failure to routinely screen and enquire into tobacco withdrawal during prison reception screening View source Inconsistent case management for prisoners moving to the Segregation Unit View source Inadequate caremap planning 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
Adrian Johnson · 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
Adrian Johnson died by an act of accidental hanging between 12.50 and 13.55 on 13 May 2010 in the Segregation Unit of HMP Belmarsh. The report identified failures in initial screening and ACCT review processes, including inadequate attention to mental health assessment, medication needs, nicotine dependency, clinical information and protection measures. Concerns remained about prison screening for tobacco withdrawal and the consistency and adequacy of ACCT case management and observation decisions for vulnerable prisoners.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to secure complete health care information for ACCT reviews
Wider context from the report “(1) Expert opinion has been given that the failure to routinely screen for and enquire into tobacco withdrawal as part of prison reception screening creates risks to the lives of a small number of vulnerable prisoners. Withdrawal problems may be interpreted by staff as behaviour designed to gain benefits, unless an appropriate health care assessment is conducted. Health care staff at HMP Belmarsh do not appear to be trained to conduct such screening, nor manage withdrawal, nor is it clear whose responsibility it would be.
(2) To questioning about steps that HMP had taken to reduce future risks, a governor reported a significant improvement in the conduct of ACCT reviews and pleasing spot checks. However she could not confirm whether there had been any individual learning by those involved. It was not clear that there would be any better consistency of case management in prisoners who move to the Segregation Unit, nor in the way in which members were asked to attend, nor the adequacy of caremap planning. The discipline staff appeared to blame the health care staff for the incomplete health care information at reviews , but there was no indication that they accepted that the case manager and chair had responsibilities to secure the information if it was not volunteered . It remained unclear how decisions on reduction of observations would in future be fully informed in exceptional cases where vulnerable prisoners are in the Segregation Unit. Improvements in the processes and conduct of ACCT reviews may not have fully addressed the areas of concern, which create significant risks for vulnerable prisoners
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Lack of health care staff training to manage tobacco withdrawal
Wider context from the report “(1) Expert opinion has been given that the failure to routinely screen for and enquire into tobacco withdrawal as part of prison reception screening creates risks to the lives of a small number of vulnerable prisoners. Withdrawal problems may be interpreted by staff as behaviour designed to gain benefits, unless an appropriate health care assessment is conducted. Health care staff at HMP Belmarsh do not appear to be trained to conduct such screening, nor manage withdrawal , nor is it clear whose responsibility it would be.
(2) To questioning about steps that HMP had taken to reduce future risks, a governor reported a significant improvement in the conduct of ACCT reviews and pleasing spot checks. However she could not confirm whether there had been any individual learning by those involved. It was not clear that there would be any better consistency of case management in prisoners who move to the Segregation Unit, nor in the way in which members were asked to attend, nor the adequacy of caremap planning. The discipline staff appeared to blame the health care staff for the incomplete health care information at reviews, but there was no indication that they accepted that the case manager and chair had responsibilities to secure the information if it was not volunteered. It remained unclear how decisions on reduction of observations would in future be fully informed in exceptional cases where vulnerable prisoners are in the Segregation Unit. Improvements in the processes and conduct of ACCT reviews may not have fully addressed the areas of concern, which create significant risks for vulnerable prisoners
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Inconsistent requests for members to attend ACCT reviews
Wider context from the report “(1) Expert opinion has been given that the failure to routinely screen for and enquire into tobacco withdrawal as part of prison reception screening creates risks to the lives of a small number of vulnerable prisoners. Withdrawal problems may be interpreted by staff as behaviour designed to gain benefits, unless an appropriate health care assessment is conducted. Health care staff at HMP Belmarsh do not appear to be trained to conduct such screening, nor manage withdrawal, nor is it clear whose responsibility it would be.
(2) To questioning about steps that HMP had taken to reduce future risks, a governor reported a significant improvement in the conduct of ACCT reviews and pleasing spot checks. However she could not confirm whether there had been any individual learning by those involved. It was not clear that there would be any better consistency of case management in prisoners who move to the Segregation Unit, nor in the way in which members were asked to attend , nor the adequacy of caremap planning. The discipline staff appeared to blame the health care staff for the incomplete health care information at reviews, but there was no indication that they accepted that the case manager and chair had responsibilities to secure the information if it was not volunteered. It remained unclear how decisions on reduction of observations would in future be fully informed in exceptional cases where vulnerable prisoners are in the Segregation Unit. Improvements in the processes and conduct of ACCT reviews may not have fully addressed the areas of concern, which create significant risks for vulnerable prisoners
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to establish individual learning from ACCT review involvement
Wider context from the report “(1) Expert opinion has been given that the failure to routinely screen for and enquire into tobacco withdrawal as part of prison reception screening creates risks to the lives of a small number of vulnerable prisoners. Withdrawal problems may be interpreted by staff as behaviour designed to gain benefits, unless an appropriate health care assessment is conducted. Health care staff at HMP Belmarsh do not appear to be trained to conduct such screening, nor manage withdrawal, nor is it clear whose responsibility it would be.
(2) To questioning about steps that HMP had taken to reduce future risks, a governor reported a significant improvement in the conduct of ACCT reviews and pleasing spot checks. However she could not confirm whether there had been any individual learning by those involved . It was not clear that there would be any better consistency of case management in prisoners who move to the Segregation Unit, nor in the way in which members were asked to attend, nor the adequacy of caremap planning. The discipline staff appeared to blame the health care staff for the incomplete health care information at reviews, but there was no indication that they accepted that the case manager and chair had responsibilities to secure the information if it was not volunteered. It remained unclear how decisions on reduction of observations would in future be fully informed in exceptional cases where vulnerable prisoners are in the Segregation Unit. Improvements in the processes and conduct of ACCT reviews may not have fully addressed the areas of concern, which create significant risks for vulnerable prisoners
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Unclear responsibility for tobacco-withdrawal screening and management
Wider context from the report “(1) Expert opinion has been given that the failure to routinely screen for and enquire into tobacco withdrawal as part of prison reception screening creates risks to the lives of a small number of vulnerable prisoners. Withdrawal problems may be interpreted by staff as behaviour designed to gain benefits, unless an appropriate health care assessment is conducted. Health care staff at HMP Belmarsh do not appear to be trained to conduct such screening, nor manage withdrawal, nor is it clear whose responsibility it would be .
(2) To questioning about steps that HMP had taken to reduce future risks, a governor reported a significant improvement in the conduct of ACCT reviews and pleasing spot checks. However she could not confirm whether there had been any individual learning by those involved. It was not clear that there would be any better consistency of case management in prisoners who move to the Segregation Unit, nor in the way in which members were asked to attend, nor the adequacy of caremap planning. The discipline staff appeared to blame the health care staff for the incomplete health care information at reviews, but there was no indication that they accepted that the case manager and chair had responsibilities to secure the information if it was not volunteered. It remained unclear how decisions on reduction of observations would in future be fully informed in exceptional cases where vulnerable prisoners are in the Segregation Unit. Improvements in the processes and conduct of ACCT reviews may not have fully addressed the areas of concern, which create significant risks for vulnerable prisoners
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure fully informed decisions on reducing observations for vulnerable prisoners in the Segregation Unit
Wider context from the report “(1) Expert opinion has been given that the failure to routinely screen for and enquire into tobacco withdrawal as part of prison reception screening creates risks to the lives of a small number of vulnerable prisoners. Withdrawal problems may be interpreted by staff as behaviour designed to gain benefits, unless an appropriate health care assessment is conducted. Health care staff at HMP Belmarsh do not appear to be trained to conduct such screening, nor manage withdrawal, nor is it clear whose responsibility it would be.
(2) To questioning about steps that HMP had taken to reduce future risks, a governor reported a significant improvement in the conduct of ACCT reviews and pleasing spot checks. However she could not confirm whether there had been any individual learning by those involved. It was not clear that there would be any better consistency of case management in prisoners who move to the Segregation Unit, nor in the way in which members were asked to attend, nor the adequacy of caremap planning. The discipline staff appeared to blame the health care staff for the incomplete health care information at reviews, but there was no indication that they accepted that the case manager and chair had responsibilities to secure the information if it was not volunteered. It remained unclear how decisions on reduction of observations would in future be fully informed in exceptional cases where vulnerable prisoners are in the Segregation Unit . Improvements in the processes and conduct of ACCT reviews may not have fully addressed the areas of concern, which create significant risks for vulnerable prisoners
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Lack of health care staff training to conduct tobacco-withdrawal screening
Wider context from the report “(1) Expert opinion has been given that the failure to routinely screen for and enquire into tobacco withdrawal as part of prison reception screening creates risks to the lives of a small number of vulnerable prisoners. Withdrawal problems may be interpreted by staff as behaviour designed to gain benefits, unless an appropriate health care assessment is conducted. Health care staff at HMP Belmarsh do not appear to be trained to conduct such screening , nor manage withdrawal, nor is it clear whose responsibility it would be.
(2) To questioning about steps that HMP had taken to reduce future risks, a governor reported a significant improvement in the conduct of ACCT reviews and pleasing spot checks. However she could not confirm whether there had been any individual learning by those involved. It was not clear that there would be any better consistency of case management in prisoners who move to the Segregation Unit, nor in the way in which members were asked to attend, nor the adequacy of caremap planning. The discipline staff appeared to blame the health care staff for the incomplete health care information at reviews, but there was no indication that they accepted that the case manager and chair had responsibilities to secure the information if it was not volunteered. It remained unclear how decisions on reduction of observations would in future be fully informed in exceptional cases where vulnerable prisoners are in the Segregation Unit. Improvements in the processes and conduct of ACCT reviews may not have fully addressed the areas of concern, which create significant risks for vulnerable prisoners
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely screen and enquire into tobacco withdrawal during prison reception screening
Wider context from the report “(1) Expert opinion has been given that the failure to routinely screen for and enquire into tobacco withdrawal as part of prison reception screening creates risks to the lives of a small number of vulnerable prisoners. Withdrawal problems may be interpreted by staff as behaviour designed to gain benefits, unless an appropriate health care assessment is conducted. Health care staff at HMP Belmarsh do not appear to be trained to conduct such screening, nor manage withdrawal, nor is it clear whose responsibility it would be.
(2) To questioning about steps that HMP had taken to reduce future risks, a governor reported a significant improvement in the conduct of ACCT reviews and pleasing spot checks. However she could not confirm whether there had been any individual learning by those involved. It was not clear that there would be any better consistency of case management in prisoners who move to the Segregation Unit, nor in the way in which members were asked to attend, nor the adequacy of caremap planning. The discipline staff appeared to blame the health care staff for the incomplete health care information at reviews, but there was no indication that they accepted that the case manager and chair had responsibilities to secure the information if it was not volunteered. It remained unclear how decisions on reduction of observations would in future be fully informed in exceptional cases where vulnerable prisoners are in the Segregation Unit. Improvements in the processes and conduct of ACCT reviews may not have fully addressed the areas of concern, which create significant risks for vulnerable prisoners
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Inconsistent case management for prisoners moving to the Segregation Unit
Wider context from the report “(1) Expert opinion has been given that the failure to routinely screen for and enquire into tobacco withdrawal as part of prison reception screening creates risks to the lives of a small number of vulnerable prisoners. Withdrawal problems may be interpreted by staff as behaviour designed to gain benefits, unless an appropriate health care assessment is conducted. Health care staff at HMP Belmarsh do not appear to be trained to conduct such screening, nor manage withdrawal, nor is it clear whose responsibility it would be.
(2) To questioning about steps that HMP had taken to reduce future risks, a governor reported a significant improvement in the conduct of ACCT reviews and pleasing spot checks. However she could not confirm whether there had been any individual learning by those involved. It was not clear that there would be any better consistency of case management in prisoners who move to the Segregation Unit , nor in the way in which members were asked to attend, nor the adequacy of caremap planning. The discipline staff appeared to blame the health care staff for the incomplete health care information at reviews, but there was no indication that they accepted that the case manager and chair had responsibilities to secure the information if it was not volunteered. It remained unclear how decisions on reduction of observations would in future be fully informed in exceptional cases where vulnerable prisoners are in the Segregation Unit. Improvements in the processes and conduct of ACCT reviews may not have fully addressed the areas of concern, which create significant risks for vulnerable prisoners
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Inadequate caremap planning
Wider context from the report “(1) Expert opinion has been given that the failure to routinely screen for and enquire into tobacco withdrawal as part of prison reception screening creates risks to the lives of a small number of vulnerable prisoners. Withdrawal problems may be interpreted by staff as behaviour designed to gain benefits, unless an appropriate health care assessment is conducted. Health care staff at HMP Belmarsh do not appear to be trained to conduct such screening, nor manage withdrawal, nor is it clear whose responsibility it would be.
(2) To questioning about steps that HMP had taken to reduce future risks, a governor reported a significant improvement in the conduct of ACCT reviews and pleasing spot checks. However she could not confirm whether there had been any individual learning by those involved. It was not clear that there would be any better consistency of case management in prisoners who move to the Segregation Unit, nor in the way in which members were asked to attend, nor the adequacy of caremap planning . The discipline staff appeared to blame the health care staff for the incomplete health care information at reviews, but there was no indication that they accepted that the case manager and chair had responsibilities to secure the information if it was not volunteered. It remained unclear how decisions on reduction of observations would in future be fully informed in exceptional cases where vulnerable prisoners are in the Segregation Unit. Improvements in the processes and conduct of ACCT reviews may not have fully addressed the areas of concern, which create significant risks for vulnerable prisoners
” 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 Record mental-health-team interactions with prisoners subject to open ACCTs in both SystmOne and the ACCT document.
Verbatim wording from the response “Within the ACCT process, the ACCT Assessor is expected to gather and review all available risk related information including that contained within the NOMIS notes, the F2050 (prisoner’s core record), and any recent ACCTs etc, to inform the assessment. All relevant risk information should be recorded within the ACCT, and attendees are expected to review and subsequent case review meetings are expected to be familiar with the contents of the ACCT. You will be aware that the Prisons and Probation Ombudsman recommended that a local protocol was devised to ensure that information was shared between safer custody and healthcare staff, and as a result members of the mental health in-reach team now record interaction with prisoners subject to an open ACCT both on SystmOne and within the ACCT document.” Source location 2013-0364-Response-by-NOMS
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 ACCT case-manager refresher training reinforcing multidisciplinary reviews, relocation handovers, risk-information sharing, and exceptional use of segregation.
Verbatim wording from the response “National policy contained within PSI 64/2011 “Management of prisoners at risk of harm to self, to others and from others (Safer Custody)” reminds staff of the mandatory requirement that ACCT case reviews “Be multi-disciplinary where possible”. Colleagues at HMP Belmarsh have confirmed that the Governor and all managers (including custodial managers and supervising officers) will attend further ACCT Case Manager refresher training, in part to underline the importance of a multidisciplinary attendance at case reviews, and the need to seek contributions from relevant departments, including healthcare staff and mental health” Source location 2013-0364-Response-by-NOMS
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish an Enhanced Case Review Team including relevant disciplines, additional specialist input, and higher-level operational management.
Verbatim wording from the response “In terms of attendance at ACCT case reviews, the policy recognises that “The ACCT process will operate more effectively if there is continuity in the attendance of staff from relevant departments/services. For example, if education is seen as a relevant department to attend the review, then every effort should be made to ensure the same member of staff attends the reviews, likewise with healthcare input”. The Enhanced Case Review Team will involve all relevant disciplines and include more specialists and a higher level of operational management than a typical ACCT Case Review Team.” Source location 2013-0364-Response-by-NOMS
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 care pathway with healthcare partners to screen for tobacco-withdrawal risks and provide appropriate support, including nicotine replacement therapy.
Verbatim wording from the response “NOMS accepts that despite the above range of screening during the reception process, further consideration needs to be given to identifying prisoners for whom tobacco withdrawal may give rise to an increase in suicidal feelings or self-harm, and to develop the support given to prisoners who do not have access to tobacco, or to the amount they would normally rely on. NOMS is currently working with healthcare partners to develop a care pathway, that includes an appropriate level of screening, to ensure that when tobacco is not available, or it is available but in more limited supply than the level they are used to (because they have limited funds/access to prison shop), that the relevant healthcare provider ensures that appropriate support, including Nicotine Replacement Therapy is available.” Source location 2013-0364-Response-by-NOMS
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reinforce CAREMAP reviews at each case review and record responsibility for actions and feedback at the next review.
Verbatim wording from the response “Colleagues at Belmarsh have confirmed that ACCT case managers will be reminded during the ongoing ACCT refresher training and in the updated local policy of the requirement to review the CAREMAP at each case review and record the manager who is responsible for each action and who is required to feed back at the next case review.” Source location 2013-0364-Response-by-NOMS
Open published response
Concerns raised 5 Insufficient mental health practitioner staffing capacity View source Failure to ensure continuity of the Emotional Wellbeing course View source Failure to complete PHQ9 assessments after antidepressant prescribing View source Failure to share relevant verbal and written risk information with prison staff View source Failure to provide timely follow-up after antidepressant prescribing View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
JORDAN ANTHONY BUCKTON · 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
JORDAN ANTHONY BUCKTON, aged 20, was found hanging by a ligature in his cell at HMYOI Portland on 28 January 2012. Concerns included failures to share information about his previous self-harm, to follow up after antidepressant medication was prescribed, and to continue an Emotional Wellbeing course after staff absence.
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 mental health practitioner staffing capacity
Wider context from the report “(3) The failure to continue the “Emotional Wellbeing” Course in January 2012
Mr Buckton had 4 sessions with HCA Board on this course which she regarded as successful in improving his outlook on life. However she was injured on the 1st January 2012 and off work but no other mental health staff were available to continue the course. Only 2 full time members of staff were in place to carry out the work of 5 full time mental health practitioners with 1 or occasionally 2 locum nurses employed to make up the deficiency .
Whilst the jury did not regard the failure to continue the course as causative or contributory to Mr Buckton’s death they clearly felt it was important to record that the failure to continue possibly had a detrimental affect upon Mr Buckton’s wellbeing. He had been diagnosed with a personality disorder. Evidence was given that the only effective treatment for such a disorder is by talking therapy and management strategies. Greater regard should have been given to the cessation of this course and the effect upon all prisoners involved.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure continuity of the Emotional Wellbeing course
Wider context from the report “(3) The failure to continue the “Emotional Wellbeing” Course in January 2012
Mr Buckton had 4 sessions with HCA Board on this course which she regarded as successful in improving his outlook on life. However she was injured on the 1st January 2012 and off work but no other mental health staff were available to continue the course . Only 2 full time members of staff were in place to carry out the work of 5 full time mental health practitioners with 1 or occasionally 2 locum nurses employed to make up the deficiency.
Whilst the jury did not regard the failure to continue the course as causative or contributory to Mr Buckton’s death they clearly felt it was important to record that the failure to continue possibly had a detrimental affect upon Mr Buckton’s wellbeing . He had been diagnosed with a personality disorder. Evidence was given that the only effective treatment for such a disorder is by talking therapy and management strategies. Greater regard should have been given to the cessation of this course and the effect upon all prisoners involved.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to complete PHQ9 assessments after antidepressant prescribing
Wider context from the report “(2) Follow Up After Issue of Anti-Depressant Medication
On the 6th December 2011 one of the attending GP’s ████████ prescribed Fluoxetine to Mr Buckton on the recommendation of Healthcare Assistant Board who stated that she had discussed such prescription with the Mental Health Team and felt that Mr Buckton was depressed. ████████ did not see Mr Buckton nor did she see him after that date to check the effectiveness of the medication. The jury found there was a failure by Healthcare staff to follow up Mr Buckton’s appointment with the GP and a failure to complete a PHQ9 Assessment .
If there had been a follow up appointment with Mr Buckton at the end of January 2012 it may be that raised risk of suicide would have been spotted and treated.
The expert witness ████████ was critical of this failure. He gave evidence that a follow up appointment is recommended in the Quality and Outcomes Framework Guidance to GP’s but is also a requirement of the National Institute of Clinical Excellence Guideline 90 which recommends “For people stated on anti-depressants who are not considered to be at increased risk of suicide, normally see them after 2 weeks. See them regularly thereafter for example at intervals of 2-4 weeks in the first 3 months and then at longer intervals if the response is good. Early cessation of treatment is associated with a greater risk of relapse”.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to share relevant verbal and written risk information with prison staff
Wider context from the report “(1) Information Sharing
Mr Buckton had previously hung himself in his cell at Exeter Prison on 14th February 2011 but was saved by prison staff and hospital treatment. He had also committed 3 acts of self-harm within that prison.
At the Inquest none of the wing staff at Portland were aware of his history of such acts nor had they read the C-NOMIS Record of the Potential Identified Risks form.
Evidence was given by medical witnesses that a history of previous self-harm is one of the most significant indicators of a future risk of suicide. This is also recorded in PSO 2700 and in the Self-harm Guidance issued by NOMS.
The jury reported that there was a failure to share verbal and written information within the prison in a suitable manner that all the staff members were informed so as to be able to carry out informed actions.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 follow-up after antidepressant prescribing
Wider context from the report “(2) Follow Up After Issue of Anti-Depressant Medication
On the 6th December 2011 one of the attending GP’s ████████ prescribed Fluoxetine to Mr Buckton on the recommendation of Healthcare Assistant Board who stated that she had discussed such prescription with the Mental Health Team and felt that Mr Buckton was depressed. ████████ did not see Mr Buckton nor did she see him after that date to check the effectiveness of the medication. The jury found there was a failure by Healthcare staff to follow up Mr Buckton’s appointment with the GP and a failure to complete a PHQ9 Assessment.
If there had been a follow up appointment with Mr Buckton at the end of January 2012 it may be that raised risk of suicide would have been spotted and treated.
The expert witness ████████ was critical of this failure. He gave evidence that a follow up appointment is recommended in the Quality and Outcomes Framework Guidance to GP’s but is also a requirement of the National Institute of Clinical Excellence Guideline 90 which recommends “For people stated on anti-depressants who are not considered to be at increased risk of suicide, normally see them after 2 weeks. See them regularly thereafter for example at intervals of 2-4 weeks in the first 3 months and then at longer intervals if the response is good. Early cessation of treatment is associated with a greater risk of relapse”.
” Open source report
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