15 Jan 2021 Kevin John LOVATT · Prevention of Future Deaths report Staffordshire South
View report summary
Concerns raised 2 Insufficient provision of Advanced Life Support-trained staff in the prison estate View source Lack of guidance and training on safe use of force for resistant prisoners with items in their mouths 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.
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AI-generated summary
Kevin John LOVATT · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Kevin John LOVATT was a serving prisoner at HMP Dovegate who died at the prison on 22 December 2017 after swallowing a package of illicit drugs and choking. The report identified concerns about communication, the response to choking, confusion at the scene, access to Advanced Life Support-trained staff and training on managing prisoners with items in their mouths that could compromise breathing.
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 provision of Advanced Life Support-trained staff in the prison estate
Wider context from the report “During evidence at the inquest I heard that nursing staff at HMP Dovegate (and throughout the prison estate) are trained to an Intermediate Life Support level . I realise it would be impractical for all nursing staff at prisons to be trained to an Advanced Life Support level however I was informed that at some stage there was at least one paramedic employed at HMP Dovegate who was trained to ALS level . I wonder if there might be some limited provision of ALS trained staff in the prison estate and if this could be part of the appropriate commissioning arrangements.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance and training on safe use of force for resistant prisoners with items in their mouths
Wider context from the report “Following the investigation by the Prisons and Probation Ombudsman a recommendation was made that you should ensure that there is clear guidance and training on the safe use of force when resistant prisoners have items in their mouth which might compromise their breathing . In evidence at the inquest I heard that suitable training on this topic did not appear to have been delivered and that it would be appreciated by prison staff. I wonder therefore if the national training you provide could include control and restraint for prisoners with items in their mouths.
” Open source report
Concerns raised 20 Failure to detect unlawful segregation and deprivation of basic amenities View source Failure to record RSU deselection discussions and risk assessments View source Inconsistent medication collection notification systems between prison wings View source Failure to record transfer decisions and pre-transfer checks View source Failure to conduct multidisciplinary risk assessment before RSU deselection View source Failure to assess risk before prisoner transfer View source Failure to warn receiving wings of altered self-harm risk View source Failure to prevent ACCT closure when required medical treatment is unavailable or incomplete View source Routine continuation of cell-door segregation without required safeguards View source Delayed recording of post-closure risk interviews after substantial risk change View source Insufficient IMB membership to conduct segregation oversight View source Failure to interview transferred prisoners and provide distraction materials on reception View source Failure to provide receiving wings with relevant prisoner risk information during transfer handover View source Failure to communicate adjudication delays to prisoners and wings View source Lack of a written RSU deselection protocol View source Failure to assess risk on reception and after transfer View source Failure to appoint and engage Personal Officers with prisoners View source Inconsistent medication regimes between prison wings View source Failure to reassess altered self-harm risk View source Failure of Personal Officer involvement when prisoners default from the prison regime View source See 17 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Andrew Patrick Jones · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Andrew Patrick Jones, a 37-year-old male prisoner, died after being transferred from a vulnerable-prisoner wing, unlawfully segregated and deprived of healthcare assessment, basic amenities and prescribed medication. The report identified concerns about inadequate risk assessment and communication, the absence of effective personal-officer support and transfer protocols, inconsistent medication systems, unlawful segregation, and failures relating to adjudication and monitoring. The expert psychiatric evidence stated that these factors created the “perfect storm”, and the jury concluded that the prison regime contributed to the death and added a rider of Neglect.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to detect unlawful segregation and deprivation of basic amenities
Wider context from the report “However, the message from the prison governor undertaking the adjudications that the adjudication would not occur that day and would be delayed to the following day did not reach the wing and was not conveyed to Andrew Jones. This is a breach of prison rules, did not detect that Andrew Jones was unlawfully segregated, failed to covey information to him and also failed to detect he did not even have the benefit of basic amenities such as a shower, a telephone call and fresh air .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 RSU deselection discussions and risk assessments
Wider context from the report “████████ had discussed Andrew Jones deselection from the RSU in the week before the altercation with the two SOs on the wing and that there was no entry in any prison record to reflect the discussion or an assessment of risk .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Inconsistent medication collection notification systems between prison wings
Wider context from the report “There was no adequate explanation of why prison wings operate different system for prison staff to notify prisoners to collect their medication .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to record transfer decisions and pre-transfer checks
Wider context from the report “b. Deselection of prisoners from the Residential Support Unit with no multidisciplinary assessment of past ACCT/self-harm, mental health, psychology input into the decision along with risk factors for an RSU prisoner in the wider jail
c. Misapplication by all senior officers and custody managers of wing segregation rules resulting in mass segregation of prisoners with no safety algorithm completion, enhanced checks, involvement of healthcare et cetera;
d. No risk assessment by the CM prior to transfer or the transferring wing Senior Officer prior to transfer;
e. No prison records of any discussions regarding transfer or the decision to transfer a prisoner between wings or of any checks undertaken prior to transfer
f. No risk assessment by the receiving wing senior officer either on reception of the prisoner or at any time in the next 36 hours before his death;
g. Inconsistent medication regimes without explanation;
h. Closure of ACCT forms when either medical treatments were impossible to deliver or had not been undertaken although the reduction in analgesics had occurred;
i. Records of post closure interviews been entered in the records when it was obvious that the risk profile had changed substantially since the post closure interview took place;
j. No personal officer involvement to ascertain why a prisoner may be defaulting from the prison regime.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 multidisciplinary risk assessment before RSU deselection
Wider context from the report “b. Deselection of prisoners from the Residential Support Unit with no multidisciplinary assessment of past ACCT/self-harm, mental health, psychology input into the decision along with risk factors for an RSU prisoner in the wider jail
c. Misapplication by all senior officers and custody managers of wing segregation rules resulting in mass segregation of prisoners with no safety algorithm completion, enhanced checks, involvement of healthcare et cetera;
d. No risk assessment by the CM prior to transfer or the transferring wing Senior Officer prior to transfer;
e. No prison records of any discussions regarding transfer or the decision to transfer a prisoner between wings or of any checks undertaken prior to transfer
f. No risk assessment by the receiving wing senior officer either on reception of the prisoner or at any time in the next 36 hours before his death;
g. Inconsistent medication regimes without explanation;
h. Closure of ACCT forms when either medical treatments were impossible to deliver or had not been undertaken although the reduction in analgesics had occurred;
i. Records of post closure interviews been entered in the records when it was obvious that the risk profile had changed substantially since the post closure interview took place;
j. No personal officer involvement to ascertain why a prisoner may be defaulting from the prison regime.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 risk before prisoner transfer
Wider context from the report “b. Deselection of prisoners from the Residential Support Unit with no multidisciplinary assessment of past ACCT/self-harm, mental health, psychology input into the decision along with risk factors for an RSU prisoner in the wider jail
c. Misapplication by all senior officers and custody managers of wing segregation rules resulting in mass segregation of prisoners with no safety algorithm completion, enhanced checks, involvement of healthcare et cetera;
d. No risk assessment by the CM prior to transfer or the transferring wing Senior Officer prior to transfer ;
e. No prison records of any discussions regarding transfer or the decision to transfer a prisoner between wings or of any checks undertaken prior to transfer
f. No risk assessment by the receiving wing senior officer either on reception of the prisoner or at any time in the next 36 hours before his death;
g. Inconsistent medication regimes without explanation;
h. Closure of ACCT forms when either medical treatments were impossible to deliver or had not been undertaken although the reduction in analgesics had occurred;
i. Records of post closure interviews been entered in the records when it was obvious that the risk profile had changed substantially since the post closure interview took place;
j. No personal officer involvement to ascertain why a prisoner may be defaulting from the prison regime.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 warn receiving wings of altered self-harm risk
Wider context from the report “The Senior Officer, and the senior prison management accepted that there had been a substantial alteration in risk with every protective factor now being converted into a risk factor. Furthermore, it was accepted that there was a failure to warn the receiving wing of the alteration in risk and that there was a further failure to reassess the alteration in risk.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent ACCT closure when required medical treatment is unavailable or incomplete
Wider context from the report “b. Deselection of prisoners from the Residential Support Unit with no multidisciplinary assessment of past ACCT/self-harm, mental health, psychology input into the decision along with risk factors for an RSU prisoner in the wider jail
c. Misapplication by all senior officers and custody managers of wing segregation rules resulting in mass segregation of prisoners with no safety algorithm completion, enhanced checks, involvement of healthcare et cetera;
d. No risk assessment by the CM prior to transfer or the transferring wing Senior Officer prior to transfer;
e. No prison records of any discussions regarding transfer or the decision to transfer a prisoner between wings or of any checks undertaken prior to transfer
f. No risk assessment by the receiving wing senior officer either on reception of the prisoner or at any time in the next 36 hours before his death;
g. Inconsistent medication regimes without explanation;
h. Closure of ACCT forms when either medical treatments were impossible to deliver or had not been undertaken although the reduction in analgesics had occurred ;
i. Records of post closure interviews been entered in the records when it was obvious that the risk profile had changed substantially since the post closure interview took place;
j. No personal officer involvement to ascertain why a prisoner may be defaulting from the prison regime.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Routine continuation of cell-door segregation without required safeguards
Wider context from the report “Unlawful use of segregation was routine practice since the introduction of the new rules some 3-4 years earlier. At this is a substantial understatement of what was taking place at HMP Garth. Since the time of introduction, on a jail wide basis, prisoners were routinely segregated behind their cell doors for periods after the initial four hours had expired without any of the safety features of segregation including assessment by healthcare to determine if segregation would adversely affect the health of the prisoner, authorisation by a Governor, regular checks et cetera .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Delayed recording of post-closure risk interviews after substantial risk change
Wider context from the report “b. Deselection of prisoners from the Residential Support Unit with no multidisciplinary assessment of past ACCT/self-harm, mental health, psychology input into the decision along with risk factors for an RSU prisoner in the wider jail
c. Misapplication by all senior officers and custody managers of wing segregation rules resulting in mass segregation of prisoners with no safety algorithm completion, enhanced checks, involvement of healthcare et cetera;
d. No risk assessment by the CM prior to transfer or the transferring wing Senior Officer prior to transfer;
e. No prison records of any discussions regarding transfer or the decision to transfer a prisoner between wings or of any checks undertaken prior to transfer
f. No risk assessment by the receiving wing senior officer either on reception of the prisoner or at any time in the next 36 hours before his death;
g. Inconsistent medication regimes without explanation;
h. Closure of ACCT forms when either medical treatments were impossible to deliver or had not been undertaken although the reduction in analgesics had occurred;
i. Records of post closure interviews been entered in the records when it was obvious that the risk profile had changed substantially since the post closure interview took place ;
j. No personal officer involvement to ascertain why a prisoner may be defaulting from the prison regime.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 IMB membership to conduct segregation oversight
Wider context from the report “The evidence at the inquest suggested that the membership of the IMB was insufficient to properly conduct its functions, which include segregation , which was not considered by the PPO.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 interview transferred prisoners and provide distraction materials on reception
Wider context from the report “Finally, although SO ████████, the SO on C Wing would have liked more information, he neither asked the transferring wing SO for this nor interviewed Andrew Jones when he arrived on C Wing . No adequate interview was undertaken on C Wing of Andrew Jones before his death despite the fact he was segregated nor were any distraction materials provided .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 receiving wings with relevant prisoner risk information during transfer handover
Wider context from the report “The only handover that was given by SO ████████ on the RSU to the receiving wing was that there were no non-associates and Andrew Jones was behind his door on basic regime pending adjudication. SO ████████ was unaware that Andrew Jones had been on an ACCT until after he had been sent to C Wing.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate adjudication delays to prisoners and wings
Wider context from the report “However, the message from the prison governor undertaking the adjudications that the adjudication would not occur that day and would be delayed to the following day did not reach the wing and was not conveyed to Andrew Jones . This is a breach of prison rules, did not detect that Andrew Jones was unlawfully segregated, failed to covey information to him and also failed to detect he did not even have the benefit of basic amenities such as a shower, a telephone call and fresh air.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 written RSU deselection protocol
Wider context from the report “At no time was there a written protocol for deselection . There was a form but it appeared form the evidence of ████████ on whom a ████████ relied, that this had never been used for deselection of a prisoner from the RSU at the Population Management Committee (PMC).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 risk on reception and after transfer
Wider context from the report “b. Deselection of prisoners from the Residential Support Unit with no multidisciplinary assessment of past ACCT/self-harm, mental health, psychology input into the decision along with risk factors for an RSU prisoner in the wider jail
c. Misapplication by all senior officers and custody managers of wing segregation rules resulting in mass segregation of prisoners with no safety algorithm completion, enhanced checks, involvement of healthcare et cetera;
d. No risk assessment by the CM prior to transfer or the transferring wing Senior Officer prior to transfer;
e. No prison records of any discussions regarding transfer or the decision to transfer a prisoner between wings or of any checks undertaken prior to transfer
f. No risk assessment by the receiving wing senior officer either on reception of the prisoner or at any time in the next 36 hours before his death ;
g. Inconsistent medication regimes without explanation;
h. Closure of ACCT forms when either medical treatments were impossible to deliver or had not been undertaken although the reduction in analgesics had occurred;
i. Records of post closure interviews been entered in the records when it was obvious that the risk profile had changed substantially since the post closure interview took place;
j. No personal officer involvement to ascertain why a prisoner may be defaulting from the prison regime.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 appoint and engage Personal Officers with prisoners
Wider context from the report “There is no indication in the prison records that any officer was appointed as Andrew Jones' Personal Officer and there is no indication in any of the prison records that any personal Officer interview or even time spent with Andrew Jones was either ever attempted or undertaken .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 medication regimes between prison wings
Wider context from the report “b. Deselection of prisoners from the Residential Support Unit with no multidisciplinary assessment of past ACCT/self-harm, mental health, psychology input into the decision along with risk factors for an RSU prisoner in the wider jail
c. Misapplication by all senior officers and custody managers of wing segregation rules resulting in mass segregation of prisoners with no safety algorithm completion, enhanced checks, involvement of healthcare et cetera;
d. No risk assessment by the CM prior to transfer or the transferring wing Senior Officer prior to transfer;
e. No prison records of any discussions regarding transfer or the decision to transfer a prisoner between wings or of any checks undertaken prior to transfer
f. No risk assessment by the receiving wing senior officer either on reception of the prisoner or at any time in the next 36 hours before his death;
g. Inconsistent medication regimes without explanation ;
h. Closure of ACCT forms when either medical treatments were impossible to deliver or had not been undertaken although the reduction in analgesics had occurred;
i. Records of post closure interviews been entered in the records when it was obvious that the risk profile had changed substantially since the post closure interview took place;
j. No personal officer involvement to ascertain why a prisoner may be defaulting from the prison regime.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 reassess altered self-harm risk
Wider context from the report “The Senior Officer, and the senior prison management accepted that there had been a substantial alteration in risk with every protective factor now being converted into a risk factor. Furthermore, it was accepted that there was a failure to warn the receiving wing of the alteration in risk and that there was a further failure to reassess the alteration in risk .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure of Personal Officer involvement when prisoners default from the prison regime
Wider context from the report “b. Deselection of prisoners from the Residential Support Unit with no multidisciplinary assessment of past ACCT/self-harm, mental health, psychology input into the decision along with risk factors for an RSU prisoner in the wider jail
c. Misapplication by all senior officers and custody managers of wing segregation rules resulting in mass segregation of prisoners with no safety algorithm completion, enhanced checks, involvement of healthcare et cetera;
d. No risk assessment by the CM prior to transfer or the transferring wing Senior Officer prior to transfer;
e. No prison records of any discussions regarding transfer or the decision to transfer a prisoner between wings or of any checks undertaken prior to transfer
f. No risk assessment by the receiving wing senior officer either on reception of the prisoner or at any time in the next 36 hours before his death;
g. Inconsistent medication regimes without explanation;
h. Closure of ACCT forms when either medical treatments were impossible to deliver or had not been undertaken although the reduction in analgesics had occurred;
i. Records of post closure interviews been entered in the records when it was obvious that the risk profile had changed substantially since the post closure interview took place;
j. No personal officer involvement to ascertain why a prisoner may be defaulting from the prison regime .
” Open source report
23 Mar 2020 Lewis Charles Francis · Prevention of Future Deaths report Exeter and Greater Devon
View report summary
Concerns raised 2 Insufficient understanding of the special needs and vulnerabilities of prisoners within the autistic spectrum View source Lack of a mechanism for ready transfer of people in police custody suspected of or charged with serious crime to a medium secure mental health facility for assessment or treatment 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.
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AI-generated summary
Lewis Charles Francis · 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
Lewis Charles Francis was arrested after stabbing his mother while acutely psychotic and was remanded to HM Prison Exeter after no ready medium secure mental health hospital transfer facility was available. He died at the prison on 24 April 2017 by suicide as a result of suspension by a ligature. Concerns included the lack of a ready transfer mechanism from police custody to medium secure mental health facilities, and insufficient understanding of the needs and vulnerabilities of prisoners on the autistic spectrum.
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 understanding of the special needs and vulnerabilities of prisoners within the autistic spectrum
Wider context from the report “(2) Evidence at the inquest suggested that there was an insufficient understanding of the special needs and vulnerabilities of those prisoners who are within the autistic spectrum
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Lack of a mechanism for ready transfer of people in police custody suspected of or charged with serious crime to a medium secure mental health facility for assessment or treatment
Wider context from the report “(1) At present there is no mechanism for the ready transfer of a person in police custody within the police areas of Devon and Cornwall, Avon and Somerset, Wiltshire and Gloucestershire from police custody to a medium secure mental health facility for assessment / treatment under sections 2 and 3 of the Mental Health Act 1983 where such a person is suspected of or charged with a serious crime. Such an arrangement exists in the West Midlands where a Memorandum of Understanding has been developed and agreed between relevant agencies.
” Open source report
Concerns raised 1 Failure to make significant relevant prisoner information available to all staff View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Robert Anthony Brown · 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
Robert Anthony Brown, a prisoner at Dovegate, was pronounced dead in his cell on 25 December 2018. The inquest recorded accidental death, with aspiration of gastric contents and synthetic cannabinoid receptor antagonists identified as the causes; a concern was that relevant information held in different prison systems was not available to all staff who might have benefited from it.
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 make significant relevant prisoner information available to all staff
Wider context from the report “Although there was no finding by the Jury that this was causative in respect of the death at times during the inquest it appeared that information in the central NOMIS records, information in the medical System 1 records and information available to the security department at the prison was not available to all staff at the prison who may have benefitted from having it . I did hear helpful evidence from the Head of Safer Custody ████████ that nationally efforts are being made to develop a system whereby significant relevant information about a prisoner is available to all staff. There is however no timescale for this. It strikes me that this would be very helpful and might prevent deaths in the future. I wonder if you can give me a progress report about this planned development and an indication as to when it might be implemented.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement phase-three interoperability to share risk information between NOMIS and SystmOne.
Verbatim wording from the response “As you know, the commissioning of healthcare in English prisons is the responsibility of NHS England and NHS Improvement, and they are leading on work with HMPPS to implement inter-operability between SystmOne and NOMIS, in order to enable better sharing of information between prison and healthcare staff. This is a big project and there are three phases of implementation. Approximately fifty percent of the planned development work on phase one, which is automating patient administration data sent from NOMIS to SystmOne, has been completed.” Source location 2020-0065-Response-from-the-Director-General-of-Prisons
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Automate patient administration data transfer from NOMIS to SystmOne through phase-one interoperability development.
Verbatim wording from the response “As you know, the commissioning of healthcare in English prisons is the responsibility of NHS England and NHS Improvement, and they are leading on work with HMPPS to implement inter-operability between SystmOne and NOMIS, in order to enable better sharing of information between prison and healthcare staff. This is a big project and there are three phases of implementation. Approximately fifty percent of the planned development work on phase one, which is automating patient administration data sent from NOMIS to SystmOne, has been completed.” Source location 2020-0065-Response-from-the-Director-General-of-Prisons
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate the Safer Custody Zone to enable prison, mental health and substance misuse staff to collaborate and routinely share key information.
Verbatim wording from the response “While this IT project is underway, and forms an important part of the solution to the challenges presented by the information sharing in the prison environment, work is also being done at a local level to ensure that prison staff and NHS staff work together more effectively. At Dovegate, the Safer Custody Zone was formed in 2019 to provide an area in which prison staff, the Mental Health Team and the Integrated Substance Misuse Team are able to work together each day to ensure that key information is routinely shared. The introduction of the new system will further enhance this collaborative work and will enable information to be readily accessible to all staff.” Source location 2020-0065-Response-from-the-Director-General-of-Prisons
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Further information-sharing project work is temporarily halted because the supplier was directed to prioritise COVID-19-related work.
Verbatim wording from the response “Unfortunately, further work on this initiative has been temporarily halted by Total Phoenix Partnership (TPP), the supplier responsible for SystmOne, who have been directed to focus on COVID-19 related work. This will cause a delay, currently estimated at 8 weeks, meaning delivery of the completed phase one work is now forecast for August 2020. The sharing of risk information between NOMIS and SystmOne will form part of phase three of the project implementation, and it is forecast to be completed in 2021. If you would like any further information or updates on the project, then I would suggest contacting NHS England and NHS Improvement, as they are the lead organisation for the implementation process.” Source location 2020-0065-Response-from-the-Director-General-of-Prisons
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS England and NHS Improvement lead implementation of the information-sharing project and should provide further updates.
Verbatim wording from the response “As you know, the commissioning of healthcare in English prisons is the responsibility of NHS England and NHS Improvement, and they are leading on work with HMPPS to implement inter-operability between SystmOne and NOMIS, in order to enable better sharing of information between prison and healthcare staff. This is a big project and there are three phases of implementation. Approximately fifty percent of the planned development work on phase one, which is automating patient administration data sent from NOMIS to SystmOne, has been completed.” Source location 2020-0065-Response-from-the-Director-General-of-Prisons
Open published response
6 Mar 2020 Carl John Newman · Prevention of Future Deaths report Liverpool and the Wirral
View report summary
Concerns raised 2 Lack of ready access to prison staff training records View source Failure to ensure current ACCT and safer custody process training for prison staff View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Carl John Newman · 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
Carl John Newman, aged 23, died by suicide after fashioning a ligature around his neck in a prison cell toilet area on 6 October 2017. The report identified concerns about delayed completion of a Day Two Assessment and prison staff’s access to, and records of, current ACCT and SASH training.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Lack of ready access to prison staff training records
Wider context from the report “During the Course of evidence it became apparent that prison staff did not have ready access to training records in particular ACCT & SASH training – one officer engaged in prison reception processes had not had ACCT training for over three years – and surprisingly it was another three years before he underwent SASH training. As HMP Liverpool were present throughout this investigation, the court understands that these training issues are being resolved locally. However this is a national issue and It is important that not only should HMPPS hold training records for those employed in the prison service but that each individual should have a personal training record. It would help if training certificates with expiry dates were issued after all courses with a copy being given to attendees and the record being held by the prison service. This would ensure all officers with current training could work across the prison estate, adding resilience.
What does HMPPS intend to do to ensure that all officers and staff have current training in ACCT and other safer custody processes?
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 current ACCT and safer custody process training for prison staff
Wider context from the report “During the Course of evidence it became apparent that prison staff did not have ready access to training records in particular ACCT & SASH training – one officer engaged in prison reception processes had not had ACCT training for over three years – and surprisingly it was another three years before he underwent SASH training . As HMP Liverpool were present throughout this investigation, the court understands that these training issues are being resolved locally. However this is a national issue and It is important that not only should HMPPS hold training records for those employed in the prison service but that each individual should have a personal training record. It would help if training certificates with expiry dates were issued after all courses with a copy being given to attendees and the record being held by the prison service. This would ensure all officers with current training could work across the prison estate, adding resilience.
What does HMPPS intend to do to ensure that all officers and staff have current training in ACCT and other safer custody processes ?
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update ACCT-related training packages and refresh the broader safety-training approach to reduce duplication and align content.
Verbatim wording from the response “As you know, we intend to roll out a new version of the ACCT case management system soon, and we will be taking this opportunity to update the related training packages, and to refresh our approach to safety training more broadly. This will allow us to reduce duplication between courses whilst ensuring that the content is consistent and makes appropriate links between related issues. As we develop this new set of training materials we will ensure that expectations as to which staff should attend which courses, and the frequency of refresher training, are clear.” Source location 2020-0056-Response-from-Director-General-of-Prisons
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue a staff information notice promoting myLearning access and reminding staff about refresher-training requirements.
Verbatim wording from the response “As a result of the matters that arose at the inquest, the Governor of HMP Liverpool has issued a staff information notice to promote the use of the myLearning system, and staff have been reminded that they are able to view their personal training records on it. This notice reiterates the importance of staff knowing when they need to undertake any future refresher training and will shortly be followed up with a comprehensive guide on how to use the system. There is also a local training coordinator who is available to assist staff with queries about these issues, and has responsibility for ensuring that staff are able to attend refresher training as required.” Source location 2020-0056-Response-from-Director-General-of-Prisons
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 local training coordination to assist staff and ensure attendance at required refresher training.
Verbatim wording from the response “As a result of the matters that arose at the inquest, the Governor of HMP Liverpool has issued a staff information notice to promote the use of the myLearning system, and staff have been reminded that they are able to view their personal training records on it. This notice reiterates the importance of staff knowing when they need to undertake any future refresher training and will shortly be followed up with a comprehensive guide on how to use the system. There is also a local training coordinator who is available to assist staff with queries about these issues, and has responsibility for ensuring that staff are able to attend refresher training as required.” Source location 2020-0056-Response-from-Director-General-of-Prisons
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide a comprehensive guide explaining how staff can use myLearning to access personal training records.
Verbatim wording from the response “As a result of the matters that arose at the inquest, the Governor of HMP Liverpool has issued a staff information notice to promote the use of the myLearning system, and staff have been reminded that they are able to view their personal training records on it. This notice reiterates the importance of staff knowing when they need to undertake any future refresher training and will shortly be followed up with a comprehensive guide on how to use the system. There is also a local training coordinator who is available to assist staff with queries about these issues, and has responsibility for ensuring that staff are able to attend refresher training as required.” Source location 2020-0056-Response-from-Director-General-of-Prisons
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 myLearning database provides outcomes equivalent to certificates with expiry dates for recording and monitoring staff training.
Verbatim wording from the response “on successful completion of the training, their record is updated to reflect their attendance (and pass/fail outcome for some courses). Both the learner themselves and the local training department have access to this record. Training departments are also able to run a report to see who has attended and/or passed a particular course, and when. We consider that this electronic system achieves the same outcomes as the system of certificates with expiry dates that you mention in your letter.” Source location 2020-0056-Response-from-Director-General-of-Prisons
Open published response
20 Dec 2019 Tomasz Nowosad · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 21 Insufficient availability of safer cells and CCTV-monitored cells View source Absence of timely, full and accurate clinical record keeping View source Lack of written rationale for self-harm and suicide risk assessments View source Inappropriate minimisation of prisoners’ illness or vulnerability during transfer decisions View source Inconsistent use of interpretation services during healthcare interviews and ACCT reviews View source Overreliance on prisoners’ denials and tick-box recording in suicide and self-harm risk assessment View source Inadequate ACCT review during moves from safer cells to ordinary cells View source Failure to maintain auditable cross-shift handover of relevant information View source Failure to provide coordinated interpreted communication about prisoner transfers View source Failure of prison staff to separately record self-harm and suicide risk information View source Observation regimes failing to account for predictable observation patterns View source Failure to review ACCT risk information and escalate concerns on arrival View source Failure to record attendees at healthcare interviews involving prison discipline staff View source Failure of staff to understand transfer rationale and destination suitability View source Failure to review and record relevant developing medical history before clinical interactions View source Failure to ensure prisoners understand transfer reasons and destination regimes View source Failure to identify participating healthcare staff and verify completeness of System One records View source Failure to undertake holistic and updated self-harm or suicide risk assessment View source Failure to hand over relevant ACCT risk information to receiving colleagues View source Failure of receiving-wing staff to attend final ACCT case reviews before transfer View source Failure to make appropriate documentary records for ACCT transfers View source See 18 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Tomasz Nowosad · 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
Tomasz Nowosad was found hanging by a ligature in an ordinary, non-safe cell at HMP Manchester on 2 February 2017, shortly after being transferred from the healthcare centre. The report identifies concerns about risk assessment, including reliance on his denials of suicidal thoughts, incomplete and delayed clinical records, inconsistent use of interpretation services, and his transfer to an ordinary wing despite expressed fears and mental health risks. The inquest jury concluded that the death was suicide contributed to by neglect.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Insufficient availability of safer cells and CCTV-monitored cells
Wider context from the report “5.14 It is suggested that HMPS should consider increasing the number of Safer cells throughout the whole of the prison and also having more CCTV monitored cells .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 timely, full and accurate clinical record keeping
Wider context from the report “5 5 It is suggested that there was an absence of timely, full and accurate clinical record keeping by members of GMMH mental health staff (whether they be healthcare assistants, nurses or doctors) This is a professional requirement under GMC Good Practice and the NMC code of conduct It is suggested that steps are taken to ensure this is completed in all cases and appropriate audits undertaken to check on this.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 written rationale for self-harm and suicide risk assessments
Wider context from the report “5 3 It is suggested that whenever an assessment of risk of self-harm or suicide is undertaken there is a written record made of the factors or issues involved in this or what weight or consideration was given to them and how the risk assessment was arrived at It is suggested that it would be appropriate for GMMH and HMPS to ensure that this is introduced
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Inappropriate minimisation of prisoners’ illness or vulnerability during transfer decisions
Wider context from the report “5 16 It is suggested that it is not appropriate to indicate to a patient prisoner that they are not so ill or vulnerable as others in considering a move out of the HCC because that may influence their cooperation and disclosure of their symptoms and presentation It is suggested that guidance is issued to GMMH staff about this
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 use of interpretation services during healthcare interviews and ACCT reviews
Wider context from the report “5 4 It appears that there was no consistent use of the language line interpretation service by HMPS or GMMH staff , and it is suggested that wherever an identified need for the use of this service is recognised it should be used on all healthcare interviews as well as at ACCT reviews While some prisoners may speak some, little or virtually no English, it is essential that every effort is made to ensure that they can understand, so far as it possible, the issues being raised and discussed with them.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Overreliance on prisoners’ denials and tick-box recording in suicide and self-harm risk assessment
Wider context from the report “5 1 The context of this case has to be seen in the light of the fact that in 2019 two self-inflicted deaths happened at HMP Manchester There were four in 2018 and my records indicate that there have been 29 from the beginning of 2006 up to date In view of the evidential issues highlighted above it is suggested that there has been a repeated theme in the majority of these cases that there was an over reliance and emphasis on the assumptions made by a prisoner that they “had no thoughts of self-harm or suicide” This is often simply recorded in ACCT reviews by ticking boxes on the review document . Whilst it is appropriate for this issue to be addressed whenever a prison is on an ACCT either by healthcare staff or at ACCT reviews because in many cases prisoners still go on to harm themselves or commit suicide It should not be regarded as definitive This was recognised and recorded in the latest PPO Investigation Report relating to a death that occurred on 5 April 2019
This was specifically referred to in paragraph 26 of the report which said “In previous investigation into self-inflicted deaths at Manchester, we identified weaknesses in the risk assessment of prisoners at risk of suicide and self-harm We found in particular that staff placed too much emphasis on prisoner’s presentation and did not give sufficient consideration to their risk factors”
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 ACCT review during moves from safer cells to ordinary cells
Wider context from the report “5 13 It is suggested that since that the overwhelming majority of prisoners who kill themselves do so by ligatures particular care should be taken when prisoner who is on an ACCT is moved from a safer cell to an ordinary cell and their ACCT should be carefully reviewed and the number, type and frequency of observations Prisoner can quickly get used to the regularity of observations and undertake self-harming or suicidal behaviour when they think they will not be seen or have contact from HMPS or GMMH 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 maintain auditable cross-shift handover of relevant information
Wider context from the report “5 11 It is suggested that there should be an auditable process of ensuring that all appropriate information is handed over between different shifts of GMMH and HMPS staff so that there is a continuity and consistency of available information
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to provide coordinated interpreted communication about prisoner transfers
Wider context from the report “5 15 It is suggested that it is not appropriate for GMMH clinical or Nursing Staff to put the onus or responsibility on a prisoner to interact with HMPS staff to try and understand why they may be moving from one location to another without both being present and the language line service used to try and ensure no miscommunication and that appropriate written guidance should be given to all staff
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure of prison staff to separately record self-harm and suicide risk information
Wider context from the report “5 7 It is suggested that whenever there is a healthcare interview and a member of prison discipline staff is present, records should be kept by GMMH and HMPS of who was there, but also HMPS staff should record separately within their records evidence and information relevant to the risk of self-harm or suicide
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Observation regimes failing to account for predictable observation patterns
Wider context from the report “5 13 It is suggested that since that the overwhelming majority of prisoners who kill themselves do so by ligatures particular care should be taken when prisoner who is on an ACCT is moved from a safer cell to an ordinary cell and their ACCT should be carefully reviewed and the number, type and frequency of observations Prisoner can quickly get used to the regularity of observations and undertake self-harming or suicidal behaviour when they think they will not be seen or have contact from HMPS or GMMH 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 review ACCT risk information and escalate concerns on arrival
Wider context from the report “5 9 It is suggested that receiving HMPS staff should ensure that they read and consider the ACCT file with particular emphasis on the assessment of risk of self-harm and suicide and how it has been managed to date and whether or not that needs to be reviewed on arrival Any concerns should be escalated
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to record attendees at healthcare interviews involving prison discipline staff
Wider context from the report “5 7 It is suggested that whenever there is a healthcare interview and a member of prison discipline staff is present, records should be kept by GMMH and HMPS of who was there , but also HMPS staff should record separately within their records evidence and information relevant to the risk of self-harm or suicide
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 staff to understand transfer rationale and destination suitability
Wider context from the report “5 10 It is suggested that GMMH and HMPS staff should ensure as is far as is reasonably possible that the patient prisoner has a real understanding and comprehension of the reasons for transfer and the regime to which they are going, particularly if they have been moved from the HCC when they occupied a safer cell but were going to an ordinary cell with a number of ligature points The staff themselves have to have a clear understanding of the reasons for transfer and what the new wing regime or locations means for the prisoner and whether or not it is appropriate Records should be kept of the reasoning and justification
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to review and record relevant developing medical history before clinical interactions
Wider context from the report “5 12 It is suggested that GMMH staff should ensure that when they have any clinical interactions with patient prisoners they familiarise themselves with all the developing relevant medical history including recent events and record what they have reviewed or considered
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure prisoners understand transfer reasons and destination regimes
Wider context from the report “5 10 It is suggested that GMMH and HMPS staff should ensure as is far as is reasonably possible that the patient prisoner has a real understanding and comprehension of the reasons for transfer and the regime to which they are going , particularly if they have been moved from the HCC when they occupied a safer cell but were going to an ordinary cell with a number of ligature points The staff themselves have to have a clear understanding of the reasons for transfer and what the new wing regime or locations means for the prisoner and whether or not it is appropriate Records should be kept of the reasoning and justification
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to identify participating healthcare staff and verify completeness of System One records
Wider context from the report “5 6 It is suggested that whenever there is a healthcare interaction with a patient prisoner and more than one healthcare member of staff is present, their identities should be recorded and all clinically relevant information is included within the System One records and checked between those present as being full and complete
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake holistic and updated self-harm or suicide risk assessment
Wider context from the report “5 2 PSI-64/2011 recognises that there are a number of potential triggers to self-harming behaviour or suicide All staff should be alert to the increased risk of self-harm or suicide posed by prisoners with these risk factors and should act appropriately to address any concerns, including opening an ACCT if necessary However, it is suggested that the list of factors is not exhaustive and everything needs to be considered in light of the overall picture This will usually involve discipline staff and health care staff It is suggested that thereafter, particularly if the prisoner is moved to the HCC, considering all the risk factors and the changing position taking into account the previous recorded history of the prisoner from both a health care and general prison service records This is especially so when ACCTs are being reviewed and a prisoner is being discharged from the ACCT or moved out of the limited number of safer cells available in the prison There has to be consideration of the overall or ‘big picture’ with regards to the risks that the prisoner poses
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 hand over relevant ACCT risk information to receiving colleagues
Wider context from the report “5 8 It is suggested that whenever there is a decision made to move a prisoner who is subject to an ACCT from the HCC to another location in the prison, prison staff of the receiving wing should ensure that they attend any final case reviews prior to discharge so that they are familiar with the relevant history and risks that the patient prisoner presents, make appropriate documentary records and ensure that relevant information is handed over to colleagues
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 receiving-wing staff to attend final ACCT case reviews before transfer
Wider context from the report “5 8 It is suggested that whenever there is a decision made to move a prisoner who is subject to an ACCT from the HCC to another location in the prison, prison staff of the receiving wing should ensure that they attend any final case reviews prior to discharge so that they are familiar with the relevant history and risks that the patient prisoner presents, make appropriate documentary records and ensure that relevant information is handed over to colleagues
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 appropriate documentary records for ACCT transfers
Wider context from the report “5 8 It is suggested that whenever there is a decision made to move a prisoner who is subject to an ACCT from the HCC to another location in the prison, prison staff of the receiving wing should ensure that they attend any final case reviews prior to discharge so that they are familiar with the relevant history and risks that the patient prisoner presents, make appropriate documentary records and ensure that relevant information is handed over to colleagues
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Redevelop ACCT training and deliver it to new staff and as refresher training for existing staff.
Verbatim wording from the response “The associated training packages are currently being redeveloped and will be delivered to all new staff through POEL training and made available as refresher training for existing staff. A specific session on the risks and triggers for self-harm and suicide will form a major part of this training.” Source location 2019-0445-Response-from-HMPPS
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase the availability of safer cells for governors wherever possible through the national prison safety programme.
Verbatim wording from the response “Fourth, safer cells (5.13-5.14). You are concerned that more such cells should be available, and that the movement of prisoners who are subject to ACCT from a safer cell to another location should be carefully managed. I understand the importance of reducing access to the means of suicide wherever possible. Physical safety, including increasing the provision of accommodation free of ligature points, is one of the work streams in our national prison safety programme. You will appreciate that large amounts of capital investment are necessary to improve the environment in this way, and we are not able to move as swiftly as we would want to. However, wherever possible we are increasing the numbers of safer” Source location 2019-0445-Response-from-HMPPS
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Hold and document ACCT case reviews before prisoner location moves, with receiving-location representation and transfer of relevant information.
Verbatim wording from the response “The new ACCT guidance is much clearer about the need to involve the prisoner in all decisions that are taken, including those concerning location. In advance of implementing the new system, it is now the practice at HMP Manchester for a case review to be held prior to any location move, including moves from healthcare to residential wings. These reviews are attended by a representative from the new location, providing an opportunity to discuss any concerns and issues relating to risk, including how a change to location and regime might affect risk. Notes of the review and any decisions made are recorded in both the ACCT document and in the NOMIS case notes. Where an enhanced assessment has been completed by the psychology department, this is also forwarded to the new location.” Source location 2019-0445-Response-from-HMPPS
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete changes to the redesigned ACCT form and guidance and roll them out across the prison estate.
Verbatim wording from the response “A number of your concerns relate to the Assessment, Care in Custody and Teamwork (ACCT) case management process for those identified as being at risk of self-harm or suicide. We have been working hard to improve the way that this system operates. Following a comprehensive review, we have devised a new version of the form and associated guidance, and I am pleased to note that much of what you have suggested has been adopted as part of that. We believe the new version will make the system easier to operate and thereby improve the quality of care offered to prisoners. It was piloted in ten establishments in 2019 and the feedback has been positive. We are currently making some further changes before rolling it out across the prison estate later in 2020.” Source location 2019-0445-Response-from-HMPPS
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Improve interpretation-service use at HMP Manchester by providing conference-style telephones for case reviews.
Verbatim wording from the response “Second, interpretation services (5.4). You express concern about inconsistent use of such services by staff. A national contract with The Big Word ensures the availability of interpretation services across the prison estate. The new ACCT guidance will emphasise the importance of their use throughout the process, and the new ACCT form will include prompts to consider the use of the service at every significant point, including assessments and case reviews. In advance of the roll out of the new version of ACCT, the Governor of HMP Manchester has taken action to improve the use of the service at the prison, for example by making conference style telephones available for use at case reviews.” Source location 2019-0445-Response-from-HMPPS
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Capital investment requirements prevent safer-cell environmental improvements from progressing as quickly as desired.
Verbatim wording from the response “Fourth, safer cells (5.13-5.14). You are concerned that more such cells should be available, and that the movement of prisoners who are subject to ACCT from a safer cell to another location should be carefully managed. I understand the importance of reducing access to the means of suicide wherever possible. Physical safety, including increasing the provision of accommodation free of ligature points, is one of the work streams in our national prison safety programme. You will appreciate that large amounts of capital investment are necessary to improve the environment in this way, and we are not able to move as swiftly as we would want to. However, wherever possible we are increasing the numbers of safer” Source location 2019-0445-Response-from-HMPPS
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing ACCT support is considered sufficient to manage acute risk in most cases without additional safer-cell provision.
Verbatim wording from the response “cells available to governors. At HMP Manchester there are currently fourteen safer cells. Ten are in the healthcare unit, five of which are equipped with CCTV. Four non-CCTV cells are around the prison healthcare electro-chronic doors. Whilst there are currently no plans to increase the number of safer cells, we will keep this under review.” Source location 2019-0445-Response-from-HMPPS
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The healthcare provider is responsible for responding separately to concerns about clinical issues.
Verbatim wording from the response “I am grateful to you for bringing to my attention a number of matters of concern, many of which are relevant across the prison estate. I have consulted with the Governor of HMP Manchester and, where relevant, will mention action that has been taken locally at the prison as well as work that is taking place at national level. I understand that the healthcare provider is responding separately to your concerns about clinical issues.” Source location 2019-0445-Response-from-HMPPS
Open published response
Concerns raised 3 Failure to accurately record ACCT observations in the ACCT document View source Failure to carry out required ACCT observations for vulnerable prisoners View source Inadequate and insufficiently repeated ACCT training for prison officers View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Daniel AKAM · 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
Daniel Akam, a vulnerable prisoner with a history of depression, self-harm, low mood and anxiety, was found unresponsive in his cell with a rope ligature around his neck and was declared deceased. The report identified concerns about an inadequate final ACCT review, missed and inaccurately recorded observations, and inadequate ACCT 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 to accurately record ACCT observations in the ACCT document
Wider context from the report “Failure to carry out ACCT observations recorded in the ACCT log
(1) CCTV evidence in the inquest established that 18 observations on Mr Akam were not carried out.
(2) The same 18 missed observations were recorded in the ACCT document as having been carried out, when they had not been .
(3) Five different prison officers purportedly signed various of these entries .
(4) Whilst the above missed observations occurred 24 hours prior to Daniel Akam’s death and were not contributory, the purpose of ACCT observations is to reduce the risk of suicide and self-harm in a vulnerable prisoner. If necessary observations are missed, the risk of suicide and self-harm amongst vulnerable prisoners will likely increase.
(5) The fact that the five separate officers did not carry out observations, when they recorded that they did , indicates that the problem is systemic.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out required ACCT observations for vulnerable prisoners
Wider context from the report “Failure to carry out ACCT observations recorded in the ACCT log
(1) CCTV evidence in the inquest established that 18 observations on Mr Akam were not carried out .
(2) The same 18 missed observations were recorded in the ACCT document as having been carried out, when they had not been.
(3) Five different prison officers purportedly signed various of these entries.
(4) Whilst the above missed observations occurred 24 hours prior to Daniel Akam’s death and were not contributory, the purpose of ACCT observations is to reduce the risk of suicide and self-harm in a vulnerable prisoner . If necessary observations are missed, the risk of suicide and self-harm amongst vulnerable prisoners will likely increase .
(5) The fact that the five separate officers did not carry out observations , when they recorded that they did, indicates that the problem is systemic.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 and insufficiently repeated ACCT training for prison officers
Wider context from the report “ACCT training for prison officers
(6) In addition, the evidence revealed that the prison officers did not appear to know what their own obligations and responsibilities were in relation to the ACCT procedure and processes . The general evidential picture was that of inadequate ACCT training for officers , who universally indicated that it would be helpful to have refresher training.
(7) Unless adequate and repeated ACCT training is provided for all officers, particularly for those junior and more inexperienced officers , the lives of vulnerable prisoners will not be safeguarded in accordance with the purpose of the ACCT procedure.
” Open source report
26 Nov 2019 Trevor Albert Oakley · Prevention of Future Deaths report Hampshire
View report summary
Concerns raised 2 Failure to identify increased self-harm risk in prisoners due in Court the following morning View source Failure to notify night staff of prisoners due in Court the following morning 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
Trevor Albert Oakley · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Trevor Albert Oakley was found hanging from a bedsheet ligature in his prison cell on 22 October 2018, shortly before he was due to start his trial. The inquest concluded that his death was suicide. The principal concern was that night staff were not immediately informed which prisoners were due in court the following morning, meaning increased self-harm risks might not be identified.
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 identify increased self-harm risk in prisoners due in Court the following morning
Wider context from the report “(1) I was told that the Courts will supply the Prison with a list of prisoners who are required for trial the following day, (“the List”). The List is circulated within the prison by the OMU (Offender Management Unit) and the relevant staff should receive the List to enable them to know which particular prisoners need to be unlocked for Court attendances the following day. I was told that the Night Orderly Officer will brief the night shift officers on the wings as to what is due to be happening over the course of the night shift, but it was the evidence of more than one Prison Officer on duty that there was no notification of the prisoners due in Court the next morning. The stance adopted within the prison appeared to be that the information was available if a Prison Officer wanted to go and look for it within the system.
(2) I am concerned that within the Prison it is not immediately apparent to the night staff who is due in Court the following morning from this, it flows, that any increased risk of self-harm by such prisoner(s) is not identified .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 notify night staff of prisoners due in Court the following morning
Wider context from the report “(1) I was told that the Courts will supply the Prison with a list of prisoners who are required for trial the following day, (“the List”). The List is circulated within the prison by the OMU (Offender Management Unit) and the relevant staff should receive the List to enable them to know which particular prisoners need to be unlocked for Court attendances the following day. I was told that the Night Orderly Officer will brief the night shift officers on the wings as to what is due to be happening over the course of the night shift, but it was the evidence of more than one Prison Officer on duty that there was no notification of the prisoners due in Court the next morning . The stance adopted within the prison appeared to be that the information was available if a Prison Officer wanted to go and look for it within the system .
(2) I am concerned that within the Prison it is not immediately apparent to the night staff who is due in Court the following morning from this, it flows, that any increased risk of self-harm by such prisoner(s) is not identified.
” Open source report
20 Nov 2019 Mr Gary Leyland · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 8 Failure to redirect concerns or contact the person's GP View source Failure to update handover information about expected welfare checks View source Failure to maintain complete and reliable welfare-check records View source Lack of a staff policy for responding to self-harm or suicide issues View source Lack of a policy directing staff where to raise clearly present non-imminent concerns View source Failure to contact relevant medical or mental health services about identified concerns View source Lack of training and information for security staff on self-harm and suicide risk View source Failure to conduct updated risk assessments View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Mr Gary Leyland · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mr Gary Leyland was found deceased in his supported accommodation on 13 November 2019 after taking excessive prescribed medication, with the inquest conclusion recording suicide and morphine toxicity. Concerns included failures to contact medical or mental health services after suicidal thoughts were disclosed, poor documentation and handover information, the use of security staff for welfare checks without clear evidence of training, and the absence of an updated risk assessment.
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 redirect concerns or contact the person's GP
Wider context from the report “5. The Court heard evidence that Oldham Council who commissioned the supported accommodation through Jigsaw Homes Group. The Court heard evidence part of the contract provision for the service includes the fact that Threshold ( the brand of Jigsaw Homes which provided the Spring Street accommodation ) must comply with certain policies which included risk assessment and risk management and Safeguarding Adults. However no evidence was provided to the Court as to any self-harm or suicide policy available to staff relating to how they should deal with such issues which may arise. In this case Spring Street clearly took responsibility by virtue of their plan (welfare checks, update risk assessment etc) for Mr Leylands welfare once they were put on notice of the Probation Service concerns. No attempt was made to re-direct the Probation Service to another agency ie Mr Leylands GP nor was any attempt made by Spring Street to contact Mr Leylands GP.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to update handover information about expected welfare checks
Wider context from the report “2. Only the handover sheets for the 7th and 8th November were updated to advise staff to “keep an eye” on Mr Leyland. NO updates were on the handover sheets for the 9-12th November despite the evidence being welfare checks would still have been expected on these dates. It is therefore unclear how security staff working the 10th and 11th November (weekend) would have been able to expect to check on Mr Leyland.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain complete and reliable welfare-check records
Wider context from the report “1. Documentation and Recording of Information - during the course of the Inquest the Court was provided with and taken to various documents and records relating to Mr Leyland. The Court found the recording and documentation to be of a poor quality and standard. The chronology document was not complete, information as to when Mr Leyland had been seen was missing. The observational log was completed in some instances with the use of an X as opposed to the staff members initials so it was not clear if he had been seen and if so by whom.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 staff policy for responding to self-harm or suicide issues
Wider context from the report “5. The Court heard evidence that Oldham Council who commissioned the supported accommodation through Jigsaw Homes Group. The Court heard evidence part of the contract provision for the service includes the fact that Threshold ( the brand of Jigsaw Homes which provided the Spring Street accommodation ) must comply with certain policies which included risk assessment and risk management and Safeguarding Adults. However no evidence was provided to the Court as to any self-harm or suicide policy available to staff relating to how they should deal with such issues which may arise. In this case Spring Street clearly took responsibility by virtue of their plan (welfare checks, update risk assessment etc) for Mr Leylands welfare once they were put on notice of the Probation Service concerns. No attempt was made to re-direct the Probation Service to another agency ie Mr Leylands GP nor was any attempt made by Spring Street to contact Mr Leylands GP.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 policy directing staff where to raise clearly present non-imminent concerns
Wider context from the report “1. Due to the fact Mr Leyland was residing in supported accommodation the Probation Officer reported her concerns to the Spring Street. However no attempt was made to contact any medical practitioner ie GP or mental health services. It was unclear at the conclusion of the Inquest whether there is a policy within the Probation for staff vindicating to whom concerns should be raised for example if Mr Leyland had been residing in his own home and where the risk is not believed to be imminent although clearly present.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 contact relevant medical or mental health services about identified concerns
Wider context from the report “1. Due to the fact Mr Leyland was residing in supported accommodation the Probation Officer reported her concerns to the Spring Street. However no attempt was made to contact any medical practitioner ie GP or mental health services. It was unclear at the conclusion of the Inquest whether there is a policy within the Probation for staff vindicating to whom concerns should be raised for example if Mr Leyland had been residing in his own home and where the risk is not believed to be imminent although clearly present.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 training and information for security staff on self-harm and suicide risk
Wider context from the report “3. The fact that the expectation was security staff would be expected to conduct welfare checks at a weekend was heard for the first time in evidence. There was no evidence as to how they are trained, what information is provided to them about self -harm and the risk of suicide. This practice was of grave concern to the Court.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 updated risk assessments
Wider context from the report “4. The Court heard there was no updated risk assessment conducted as was envisaged following the email from the Probation Service.
” Open source report
19 Nov 2019 Shaun William Dewey · Prevention of Future Deaths report Avon
View report summary
Concerns raised 4 Failure to reflect remand prisoners’ higher risk of self-harm or suicide in national safer-custody guidance View source Failure to highlight remand prisoners’ higher risk of self-harm or suicide on the ACCT document View source Failure to incorporate the higher risk of self-harm or suicide among remand prisoners into staff training View source Failure to highlight the higher risk of self-harm or suicide among remand prisoners to prison and healthcare staff View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Shaun William Dewey · 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
Shaun William Dewey, a remand prisoner, was found hanging in his cell at HMP Bristol and died on 13 April 2018 after suspending himself from a ligature tied to the bed frame. The inquest identified anxiety, depression, separation from family, uncoordinated supervision, erratic medication use, and insufficient application of prison, healthcare and mental health systems as contributory factors. Concerns included whether remand prisoners’ higher risk of self-harm or suicide should be reflected in staff training, prisoner care, ACCT documentation and national guidance.
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 reflect remand prisoners’ higher risk of self-harm or suicide in national safer-custody guidance
Wider context from the report “My concern is therefore whether the risk of remand prisoners being at higher risk of self-harm or suicide should be:
• considered by those designing the training for staff;
• a factor generally highlighted to those caring for prisoners including prison staff and healthcare teams that is both the mental and physical health teams.
• a risk highlighted on the ACCT document or
• reflected in any re-draft of PSI 64/2011 national guidance – “Management of prisoners at risk of harm to self, to others and from others (safer custody)”
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to highlight remand prisoners’ higher risk of self-harm or suicide on the ACCT document
Wider context from the report “My concern is therefore whether the risk of remand prisoners being at higher risk of self-harm or suicide should be:
• considered by those designing the training for staff;
• a factor generally highlighted to those caring for prisoners including prison staff and healthcare teams that is both the mental and physical health teams.
• a risk highlighted on the ACCT document or
• reflected in any re-draft of PSI 64/2011 national guidance – “Management of prisoners at risk of harm to self, to others and from others (safer custody)”
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to incorporate the higher risk of self-harm or suicide among remand prisoners into staff training
Wider context from the report “My concern is therefore whether the risk of remand prisoners being at higher risk of self-harm or suicide should be:
• considered by those designing the training for staff ;
• a factor generally highlighted to those caring for prisoners including prison staff and healthcare teams that is both the mental and physical health teams.
• a risk highlighted on the ACCT document or
• reflected in any re-draft of PSI 64/2011 national guidance – “Management of prisoners at risk of harm to self, to others and from others (safer custody)”
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to highlight the higher risk of self-harm or suicide among remand prisoners to prison and healthcare staff
Wider context from the report “My concern is therefore whether the risk of remand prisoners being at higher risk of self-harm or suicide should be:
• considered by those designing the training for staff;
• a factor generally highlighted to those caring for prisoners including prison staff and healthcare teams that is both the mental and physical health teams.
• a risk highlighted on the ACCT document or
• reflected in any re-draft of PSI 64/2011 national guidance – “Management of prisoners at risk of harm to self, to others and from others (safer custody)”
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Disseminated guidance identifying remand status as a suicide and self-harm risk factor.
Verbatim wording from the response “As you rightly point out, whilst Prison Service Instruction (PSI) 64/2011 ‘Safer Custody’ contains lists of identified risks and triggers for suicide and self-harm that include factors that are relevant to many remand prisoners (such as early days in custody), it does not mention remand status itself. However, we frequently supplement the list in the PSI with additional information for staff, and this has included references to the increased risk posed by remand prisoners. For instance, the April 2014 Prison and Probation Ombudsman learning bulletin, from which you have quoted in your report, was disseminated widely within prisons, and more recent guidance issued by our prison safety team and made available to staff on the HMPPS intranet includes remand status as a risk factor for suicide. Training based on this more recent guidance has also been provided to staff in a number of prisons.” Source location 2019-0398-Response-from-Director-General-of-Prisons_Redacted-1
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and include a revised ACCT process in the new prison-safety policy framework, incorporating evaluation feedback before national rollout.
Verbatim wording from the response “During 2020 we will be replacing PSI 64/2011 with a policy framework on prison safety, and as part of this process the lists of risks and triggers will be reviewed and updated. We will ensure that the evidence about the risks posed by remand status, which you have drawn to my attention, is used to inform that work. The new policy framework will include a new version of the Assessment, Care in Custody and Teamwork (ACCT) process designed to make the system easier to operate and improve the quality of care offered to prisoners. The new version of the form and associated guidance were piloted in ten establishments in 2019 and the initial feedback has been positive. We are currently considering the formal” Source location 2019-0398-Response-from-Director-General-of-Prisons_Redacted-1
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Replace the existing safer-custody instruction with a policy framework and update risk and trigger lists using evidence on remand-status risks.
Verbatim wording from the response “During 2020 we will be replacing PSI 64/2011 with a policy framework on prison safety, and as part of this process the lists of risks and triggers will be reviewed and updated. We will ensure that the evidence about the risks posed by remand status, which you have drawn to my attention, is used to inform that work. The new policy framework will include a new version of the Assessment, Care in Custody and Teamwork (ACCT) process designed to make the system easier to operate and improve the quality of care offered to prisoners. The new version of the form and associated guidance were piloted in ten establishments in 2019 and the initial feedback has been positive. We are currently considering the formal” Source location 2019-0398-Response-from-Director-General-of-Prisons_Redacted-1
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provided staff training based on guidance recognising remand status as a suicide and self-harm risk factor.
Verbatim wording from the response “As you rightly point out, whilst Prison Service Instruction (PSI) 64/2011 ‘Safer Custody’ contains lists of identified risks and triggers for suicide and self-harm that include factors that are relevant to many remand prisoners (such as early days in custody), it does not mention remand status itself. However, we frequently supplement the list in the PSI with additional information for staff, and this has included references to the increased risk posed by remand prisoners. For instance, the April 2014 Prison and Probation Ombudsman learning bulletin, from which you have quoted in your report, was disseminated widely within prisons, and more recent guidance issued by our prison safety team and made available to staff on the HMPPS intranet includes remand status as a risk factor for suicide. Training based on this more recent guidance has also been provided to staff in a number of prisons.” Source location 2019-0398-Response-from-Director-General-of-Prisons_Redacted-1
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise suicide and self-harm prevention training and update its risk-and-trigger recognition module to reflect the new policy framework and ACCT changes.
Verbatim wording from the response “evaluation report and expect to make some further changes before the national rollout. I will ensure that your point about the need to bring attention to the risks associated with remand status is considered as we do so. We will also be revising the Introduction to Suicide and Self Harm Prevention training (a course that is undertaken by all staff with prisoner contact) to reflect and support the new policy framework and changes to ACCT. Again, we will use this opportunity to ensure that the module on recognising risks and triggers is reviewed and updated.” Source location 2019-0398-Response-from-Director-General-of-Prisons_Redacted-1
Open published response
5 Nov 2019 Neville Lewis MCNAIR · Prevention of Future Deaths report East Sussex
View report summary
Concerns raised 4 Unavailability of Naloxone on prison wings outside the healthcare wing View source Lack of a local protocol for accessing and administering Naloxone View source Lack of prison officer training in Naloxone use View source Failure of prison staff to know the Naloxone requirement and availability 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
Neville Lewis MCNAIR · 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
Neville Lewis MCNAIR was found unresponsive in his cell at HMP Lewes on 16 June 2018 and could not be revived after extensive CPR. The inquest concluded that the cause involved heroin toxicity with aspiration, and raised concerns about the availability of Naloxone in prison wings and prison officers’ training and awareness of its use.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Unavailability of Naloxone on prison wings outside the healthcare wing
Wider context from the report “In the Drug misuse and dependence: UK guidelines on clinical management “Orange Book” setting out UK guidelines on clinical management, section 5.4.9.1 states that ‘all staff including non-health care staff and operational/security staff should have training in recognising and responding to opiate overdose including using available Naloxone. Naloxone should be available in resuscitation kits and risk assessed areas in the prison so that it can be accessed and administered by clinical and non-clinical staff as per the local protocol.’ The Inquest was unable to establish that there was a local protocol and none of the prison staff were aware of the requirement. I am concerned that there is no Naloxone stored on the wings other than in healthcare wing and no prison officers appear to have been trained in its use or know of its existence. I believe this may be a national issue and not limited to HMP Lewes and in these circumstances this report should be seen as a concern for all prisons and NHS staff working in prisons nationally.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 local protocol for accessing and administering Naloxone
Wider context from the report “In the Drug misuse and dependence: UK guidelines on clinical management “Orange Book” setting out UK guidelines on clinical management, section 5.4.9.1 states that ‘all staff including non-health care staff and operational/security staff should have training in recognising and responding to opiate overdose including using available Naloxone. Naloxone should be available in resuscitation kits and risk assessed areas in the prison so that it can be accessed and administered by clinical and non-clinical staff as per the local protocol.’ The Inquest was unable to establish that there was a local protocol and none of the prison staff were aware of the requirement. I am concerned that there is no Naloxone stored on the wings other than in healthcare wing and no prison officers appear to have been trained in its use or know of its existence. I believe this may be a national issue and not limited to HMP Lewes and in these circumstances this report should be seen as a concern for all prisons and NHS staff working in prisons nationally.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Lack of prison officer training in Naloxone use
Wider context from the report “In the Drug misuse and dependence: UK guidelines on clinical management “Orange Book” setting out UK guidelines on clinical management, section 5.4.9.1 states that ‘all staff including non-health care staff and operational/security staff should have training in recognising and responding to opiate overdose including using available Naloxone. Naloxone should be available in resuscitation kits and risk assessed areas in the prison so that it can be accessed and administered by clinical and non-clinical staff as per the local protocol.’ The Inquest was unable to establish that there was a local protocol and none of the prison staff were aware of the requirement. I am concerned that there is no Naloxone stored on the wings other than in healthcare wing and no prison officers appear to have been trained in its use or know of its existence. I believe this may be a national issue and not limited to HMP Lewes and in these circumstances this report should be seen as a concern for all prisons and NHS staff working in prisons nationally.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure of prison staff to know the Naloxone requirement and availability
Wider context from the report “In the Drug misuse and dependence: UK guidelines on clinical management “Orange Book” setting out UK guidelines on clinical management, section 5.4.9.1 states that ‘all staff including non-health care staff and operational/security staff should have training in recognising and responding to opiate overdose including using available Naloxone. Naloxone should be available in resuscitation kits and risk assessed areas in the prison so that it can be accessed and administered by clinical and non-clinical staff as per the local protocol.’ The Inquest was unable to establish that there was a local protocol and none of the prison staff were aware of the requirement . I am concerned that there is no Naloxone stored on the wings other than in healthcare wing and no prison officers appear to have been trained in its use or know of its existence . I believe this may be a national issue and not limited to HMP Lewes and in these circumstances this report should be seen as a concern for all prisons and NHS staff working in prisons nationally.
” 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 Determine how prison staff could identify opioid overdoses and administer naloxone, including the training required.
Verbatim wording from the response “I am committed to working with NHSE&I to make naloxone more readily available across the prison estate. This is not straightforward, and there are risks to both staff and prisoners that need to be managed. For this reason, the current position is that it is being administered only by healthcare professionals. There are a number of issues that require further consideration before we can move forward to involve prison staff more widely. Identifying a potential opioid overdose and administering treatment for it has not previously been a part of the role of prison officers and other non-clinical staff in prisons, and we will need to consider precisely how this will work in practice, and what training we will need to provide to equip staff to take it on. We will also need to consult trade unions as we develop our approach.” Source location Response from HM Prisons and Probation Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Prepare a pilot to train prison staff in selected prisons in northern England.
Verbatim wording from the response “We are working to determine the best way of managing the risks. Consideration is being given to the use of alternatives to intramuscular naloxone, such as nyxoid, a nasal form of naloxone. We are also preparing a pilot project to train prison staff in a number of prisons in” Source location Response from HM Prisons and Probation Service
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Broader prison staff administration of naloxone cannot yet proceed because risks, role requirements, training needs and trade union consultation require further consideration.
Verbatim wording from the response “I am committed to working with NHSE&I to make naloxone more readily available across the prison estate. This is not straightforward, and there are risks to both staff and prisoners that need to be managed. For this reason, the current position is that it is being administered only by healthcare professionals. There are a number of issues that require further consideration before we can move forward to involve prison staff more widely. Identifying a potential opioid overdose and administering treatment for it has not previously been a part of the role of prison officers and other non-clinical staff in prisons, and we will need to consider precisely how this will work in practice, and what training we will need to provide to equip staff to take it on. We will also need to consult trade unions as we develop our approach.” Source location Response from HM Prisons and Probation Service
Open published response
5 Oct 2019 Master Alex Malcolm · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 3 Inadequate arrangements for responding to domestic violence View source Difficulties in recruitment and retention of probation officers View source Insufficient availability of Approved Premises places View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Master Alex Malcolm · 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
Master Alex Malcolm, aged 5, died on 22 November 2016 from a head injury and was found to have been unlawfully killed; a perpetrator was convicted of murder. The jury identified concerns including the perpetrator’s misclassification, failures to share information and safeguard the deceased’s mother, inadequate probation supervision, failure to secure approved premises, and failures to respond to licence breaches. Further concerns included shortages of approved premises, domestic-violence safeguarding arrangements, and recruitment and retention difficulties among probation 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 Inadequate arrangements for responding to domestic violence
Wider context from the report “2. The Chair of the Serious Case Review subgroup of Lambeth Safeguarding Children Board said that strengthening any arrangements around domestic violence , including putting MARACs on a statutory basis had the potential to save lives. The senior Coroner raised this issue in a Prevention of Future Deaths Report to the Secretary of State for Health earlier this year, triggered by the chair of a domestic homicide review into the death of Donna Williamson. Her evidence was clear that there were arguments for MARAC and other bodies to be put on a statutory footing and for the system to be reviewed . The response from the ministry did not specifically address the issue.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Difficulties in recruitment and retention of probation officers
Wider context from the report “3. A senior NPS divisional head said that there were still difficulties in recruitment and retention of probation officers , one factor in which was low pay. It is understood the matter is under review but details of what steps have since been taken and their adequacy were not heard by the coroner.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 availability of Approved Premises places
Wider context from the report “1. A senior NPS divisional head said that providing more Approved Premises places would potentially save lives . It is understood the matter is under review but details of what steps have since been taken were not heard by the coroner.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce beneficial pay-on-promotion arrangements to support career progression and vacancy filling.
Verbatim wording from the response “NPS Pay Modernisation included a two-year pensionable pay award (2018-19 and 2019-20) for all staff. Approximately 9,500 staff received a minimum pay award of 3 per cent in each year (instead of a contractual 1 per cent pay award if the pay reforms had not been implemented). The new pay structures also recognised staff at the maximum of their grade and provide a framework for pay progression for all staff through a competency-based framework. New arrangements, such as a more beneficial pay-on-promotion policy, were also introduced to support career progression and to assist the filling of vacancies on a temporary and permanent basis.” Source location 2019-0344-Response-by-HM-Prison-and-Probation-Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Pay market-forces allowances to probation staff in specified locations to address local recruitment and retention difficulties.
Verbatim wording from the response “NPS staff based in London also receive a London Allowance of £3,889 per annum. In addition, a ‘Market Forces Allowance’ of £1,100 to £3,100 is currently being paid to” Source location 2019-0344-Response-by-HM-Prison-and-Probation-Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue monitoring recruitment and retention and assess implementation of the new pay structure.
Verbatim wording from the response “HMPPS continues to monitor recruitment and retention, and to assess the implementation of the new pay structure. I hope that the measures I have described above demonstrate the continued work being done in this area.” Source location 2019-0344-Response-by-HM-Prison-and-Probation-Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce and operate modernised probation pay structures, including pensionable pay awards and competency-based progression.
Verbatim wording from the response “You refer to difficulties in recruiting and retaining probation officers and the steps being taken to address these. HMPPS introduced a new pay structure with effect from 1 April 2018 for the National Probation Service (NPS) to recognise the professional nature of the work of its staff and the significant contribution they make. As part of this process, pay for the NPS was compared against other public sector employment, to ensure that it was competitive.” Source location 2019-0344-Response-by-HM-Prison-and-Probation-Service
Open published response
4 Sep 2019 Imran Mahmood · Prevention of Future Deaths report Staffordshire South
View report summary
Concerns raised 2 E-cigarettes capable of starting fires View source E-cigarettes enabling drug use through accessible heating components View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Imran Mahmood · 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
Imran Mahmood, a serving prisoner, was found dead in his cell at HMP Dovegate on 16 July 2018 after taking more heroin than his body could cope with; the inquest recorded morphine/heroin poisoning. The report raised concerns that e-cigarette heating coils could be used to cook heroin and could also present a fire risk in prisons.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation E-cigarettes capable of starting fires
Wider context from the report “Imran had cooked the heroin he took by using the heating coil in an e-cigarette (vaping device). I have previously dealt with a prison death in similar circumstances. I am aware that prisoners should be allowed e-cigarettes should they want them. However they do present a danger not just by way of drug use but also the ability to start fires . I wonder if e-cigarettes used in the prison estate could be manufactured so that the heating component is in a sealed unit.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation E-cigarettes enabling drug use through accessible heating components
Wider context from the report “Imran had cooked the heroin he took by using the heating coil in an e-cigarette (vaping device). I have previously dealt with a prison death in similar circumstances. I am aware that prisoners should be allowed e-cigarettes should they want them. However they do present a danger not just by way of drug use but also the ability to start fires. I wonder if e-cigarettes used in the prison estate could be manufactured so that the heating component is in a sealed unit.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue assessing commercially available alternative nicotine-delivery devices against security, safety and commercial criteria.
Verbatim wording from the response “We are aware of these risks and continue to seek the safest options available. We are not in a position to fund the development and manufacture of these products, so we are limited to what is commercially available. We are also constrained by cost, as we are not permitted to subsidise sales to prisoners and must offer products that are affordable to them. However, we are currently considering alternative vape devices, including a new device that is not an e-cigarette and has no electronics, batteries, heat or vapour, instead using vapourless technology to deliver a low dose of nicotine. If and when we identify an alternative device that is suitable on security, safety and commercial grounds we will make it available across the estate.” Source location 2019-0355-Response-by-HM-Prison-and-Probation-Services
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Products cannot be subsidised for prisoners, and cost constraints require available vaping devices to remain affordable.
Verbatim wording from the response “We are aware of these risks and continue to seek the safest options available. We are not in a position to fund the development and manufacture of these products, so we are limited to what is commercially available. We are also constrained by cost, as we are not permitted to subsidise sales to prisoners and must offer products that are affordable to them. However, we are currently considering alternative vape devices, including a new device that is not an e-cigarette and has no electronics, batteries, heat or vapour, instead using vapourless technology to deliver a low dose of nicotine. If and when we identify an alternative device that is suitable on security, safety and commercial grounds we will make it available across the estate.” Source location 2019-0355-Response-by-HM-Prison-and-Probation-Services
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Development and manufacture of safer vaping products cannot be funded, limiting available options to commercially produced devices.
Verbatim wording from the response “We are aware of these risks and continue to seek the safest options available. We are not in a position to fund the development and manufacture of these products, so we are limited to what is commercially available. We are also constrained by cost, as we are not permitted to subsidise sales to prisoners and must offer products that are affordable to them. However, we are currently considering alternative vape devices, including a new device that is not an e-cigarette and has no electronics, batteries, heat or vapour, instead using vapourless technology to deliver a low dose of nicotine. If and when we identify an alternative device that is suitable on security, safety and commercial grounds we will make it available across the estate.” Source location 2019-0355-Response-by-HM-Prison-and-Probation-Services
Open published response
16 Aug 2019 Martin Leslie Haines · Prevention of Future Deaths report East Sussex
View report summary
Concerns raised 7 Failure to carry out diagnostic testing and monitoring for diabetes View source Fragmentation of responsibility for prison healthcare across multiple organisations View source Standard of care falling below community level View source Failure to confirm cardiovascular disease View source Availability of means to brew or distil alcohol View source Lack of protocols or agreements for responding to an unresponsive body View source Insufficient communication and information sharing between prison healthcare organisations View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Martin Leslie Haines · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Martin Leslie Haines was detained at Lewes Prison and was found dead in his cell on 18 March 2018. He had Type II Diabetes and warning signs of cerebrovascular disease, but the appropriate diagnostic tests were not carried out; alcohol, Venlafaxine and Amitriptyline were later found in his system and considered by the pathologist to have contributed to his death. The principal concerns included inadequate diabetes and cardiovascular monitoring, healthcare falling below community standards, the ability to brew or distil alcohol in prison, a lack of protocols for responding to an unresponsive body, and insufficient communication between healthcare providers and the prison service.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out diagnostic testing and monitoring for diabetes
Wider context from the report “(2) The failure to carry out diagnostic testing and monitoring for his diabetes and to confirm his considerable cardiovascular disease.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Fragmentation of responsibility for prison healthcare across multiple organisations
Wider context from the report “(5) In my opinion, the underlying problems were due to the fact that responsibility for healthcare in the prison was split between the prison service, Sussex Partnership Foundation Trust (which is a mental health provider but was also contracted to run all healthcare, both physical and mental within the prison), Medco Ltd who provided the GPs and Forward Trust who were contracted to treat alcohol and substance misuse in the prison . There was insufficient communication between these bodies and they had separate IT databases.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Standard of care falling below community level
Wider context from the report “(3) The standard of care appears to have fallen well below that which he could have received in the community .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to confirm cardiovascular disease
Wider context from the report “(2) The failure to carry out diagnostic testing and monitoring for his diabetes and to confirm his considerable cardiovascular disease .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Availability of means to brew or distil alcohol
Wider context from the report “(1) The fact that the deceased was able to brew or distil his own alcohol .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Lack of protocols or agreements for responding to an unresponsive body
Wider context from the report “(4) There were no protocols or agreements between healthcare staff and the prison service as to how best to respond to an unresponsive body .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Insufficient communication and information sharing between prison healthcare organisations
Wider context from the report “(5) In my opinion, the underlying problems were due to the fact that responsibility for healthcare in the prison was split between the prison service, Sussex Partnership Foundation Trust (which is a mental health provider but was also contracted to run all healthcare, both physical and mental within the prison), Medco Ltd who provided the GPs and Forward Trust who were contracted to treat alcohol and substance misuse in the prison. There was insufficient communication between these bodies and they had separate IT databases .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and update HMP Lewes’s local Substance Misuse Strategy to address illicitly brewed alcohol, consequences and support for dependent users.
Verbatim wording from the response “Each prison has responsibility for reviewing their own local substance misuse strategy, which sets out how they identify residents with drug and alcohol issues and provide them with a range of services to help them to overcome their substance misuse problems and lead healthier, crime-free lives both in prison and in the community.” Source location Response from HM Prison and Probation Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase security procedures by checking known brewing locations and carefully selecting and searching kitchen workers with access to alcohol-production ingredients.
Verbatim wording from the response “At HMP Lewes the local Substance Misuse Strategy was reviewed and updated in June 2019 to include a section on illicitly brewed alcohol. The strategy focuses on restricting availability, ensuring that there are appropriate consequences for those found in possession of alcohol, and offering appropriate support for dependent users. There has been an increase in security procedures to include thorough checks of known brewing locations, as” Source location Response from HM Prison and Probation Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Display control-room reminders and regularly issue staff notices requiring correct use of emergency codes and immediate ambulance calls.
Verbatim wording from the response “Your fourth concern relates to the lack of a protocol between prison and healthcare staff as to how best to respond to an unresponsive body. In accordance with Prison Service Instruction 03/2013, all prisons are required to have in place a two-code medical emergency response system and, when used correctly, these codes should trigger the control room to call an ambulance and for healthcare staff to attend the scene with the appropriate emergency equipment. You may recall from evidence heard at the inquest that a notice is now displayed in the control room to serve as a visual reminder to staff of the need to call an ambulance immediately upon receiving an emergency code. The prison also issues notices to all staff regularly to remind them of the importance of using the emergency codes correctly.” Source location Response from HM Prison and Probation Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish the Prisons Drug Strategy to reduce the availability and use of drugs and alcohol in prisons.
Verbatim wording from the response “Your first concern is that Mr Haines was able to brew his own alcohol. I share your concern, and would like to assure you that there has been a lot of work at national and local levels to tackle the availability and use of illegal substances in prison. In April 2019 the Prisons Drug Strategy was published. This guidance was developed in partnership between the Ministry of Justice and HMPPS with input from partner agencies in health, law enforcement and social care. The core aim of this strategy and our surrounding activity is to reduce the impact of drugs and alcohol in prisons by restricting supply, reducing demand and building recovery.” Source location Response from HM Prison and Probation Service
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The existing two-code medical emergency response system and staff reminders address responses to unresponsive bodies.
Verbatim wording from the response “Your fourth concern relates to the lack of a protocol between prison and healthcare staff as to how best to respond to an unresponsive body. In accordance with Prison Service Instruction 03/2013, all prisons are required to have in place a two-code medical emergency response system and, when used correctly, these codes should trigger the control room to call an ambulance and for healthcare staff to attend the scene with the appropriate emergency equipment. You may recall from evidence heard at the inquest that a notice is now displayed in the control room to serve as a visual reminder to staff of the need to call an ambulance immediately upon receiving an emergency code. The prison also issues notices to all staff regularly to remind them of the importance of using the emergency codes correctly.” Source location Response from HM Prison and Probation Service
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Prison staff cannot access clinical records on SystmOne because such access is not appropriate.
Verbatim wording from the response “Your final concern is that responsibility for healthcare is split between different contractors, and that there was insufficient communication between these bodies and their separate IT databases. As you know, the commissioning of healthcare in English prisons is the responsibility of NHS England and NHS Improvement (NHSE/I). HMPPS is responsible for ensuring access to healthcare services within establishments and, where required, at external healthcare facilities. With regard to the sharing of information between the various organisations, you will appreciate that it is not appropriate for prison staff to have access to clinical records on SystmOne. At HMP Lewes, there is a daily meeting between prison and healthcare staff at which important information is shared. Each staff team then ensures that their respective databases are updated.” Source location Response from HM Prison and Probation Service
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHSE/I is responsible for commissioning healthcare in English prisons, not HMPPS.
Verbatim wording from the response “Your final concern is that responsibility for healthcare is split between different contractors, and that there was insufficient communication between these bodies and their separate IT databases. As you know, the commissioning of healthcare in English prisons is the responsibility of NHS England and NHS Improvement (NHSE/I). HMPPS is responsible for ensuring access to healthcare services within establishments and, where required, at external healthcare facilities. With regard to the sharing of information between the various organisations, you will appreciate that it is not appropriate for prison staff to have access to clinical records on SystmOne. At HMP Lewes, there is a daily meeting between prison and healthcare staff at which important information is shared. Each staff team then ensures that their respective databases are updated.” Source location Response from HM Prison and Probation Service
Open published response
Concerns raised 11 Failure to carry and use personal protective equipment View source Failure of probation staff to engage in full updating training View source Failure to challenge or support change in domestic abuse risk during probation supervision View source Failure to allocate an appropriately protective MAPPA level for offenders with significant domestic abuse histories who have not been fully tested before release View source Failure to detail licence conditions during MAPPA Level 1 management View source Failure to obtain information during initial attendances on reported domestic abuse incidents View source Insufficient probation staffing capacity for complex and demanding casework View source Failure to evidence implementation of recommended safety changes View source Lack of mandated joined-up inter-agency communication at offender release or when new personal relationships develop View source Deficiencies in initial grading of calls to identify initial responses View source Failure to maintain mandatory inter-agency information sharing for MAPPA Level 1 management View source See 8 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
Cherylee Yvette Shennan · 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
Cherylee Yvette Shennan, a 40-year-old woman, was murdered on 17 March 2014 by a former offender who had subjected her to domestic abuse, including serious violence. The report raised concerns about inadequate inter-agency communication and management of the perpetrator, including the absence of a mandatory process for sharing information when an offender with a known history of domestic abuse was managed at MAPPA Level 1.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to carry and use personal protective equipment
Wider context from the report “Following the death of Cherylee, her death, and actions taken in the months leading up to it were the subject of two detailed reviews. Following the Domestic Homicide Review a number of recommendations were made by the author of the Individual Management Report, Mr Gary Fishwick including concerns regarding initial grading of calls to identify initial responses, the obtaining of information as part of initial attendances on reported domestic abuse incidents and the carrying and use of personal protective equipment . Whilst the recommendations were made, Mr Fishwick could give no evidence at the inquest into the death of Cherylee to indicate whether those recommendations had in fact been actioned or not, and accordingly whether anything had changed following the death of Cherylee and the learning exercise that were subsequently undertaken.
In particular reference was made to, but unsupported by documentation, or any other form of evidence:
• Policies reflecting recommended changes;
• Information sharing agreements between agencies;
• MARAC emergency policy or notes;
• DASH Training or policy regarding obtaining GP details; and
• Audits of Grade 2 ‘Ethical fails’ and reasons for such fails.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure of probation staff to engage in full updating training
Wider context from the report “3) Finally it was also accepted by senior probation witnesses that although staff had access to updated training information, due to pressures of their workloads they lacked the time to engage in full updating training .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 challenge or support change in domestic abuse risk during probation supervision
Wider context from the report “2) Evidence was further heard regarding the Report of the Chief Inspector of Probation 2019 and in particular the finding that "Many individuals were drifting through their supervision period without being challenged or supported to change their prediction for domestic abuse " and that "The number of probation professionals is now at a critical level. There is a national shortage of professional probation staff and especially those mainly responsible for more complex and demanding casework". It was agreed by those senior probation witnesses that staffing and workloads had been an issue in this matter, as found by the jury, and furthermore continued to be so.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to allocate an appropriately protective MAPPA level for offenders with significant domestic abuse histories who have not been fully tested before release
Wider context from the report “1) During the course of the inquest statistics regarding the nature of domestic abuse were repeatedly reviewed and accepted by senior member of both probation and police services. In particular domestic abuse features in about half of all cases managed by probation staff and that in the year to the end of 2018 of the 659 homicides 1 in 10 were committed by a partner. Evidence was heard of the MAPPA process, for the managing of risk of offenders to be released on licence, and for the interagency sharing of information regarding those offenders. During the course of the evidence it was made clear that the perpetrator in this instance was a very dangerous individual, who was described as controlling and manipulative, and who, it was accepted by the witnesses involved in his management, was likely to have controlled his meetings by his nature, and by partial disclosures of information. The underlying issue that arose from both the various reviews that took place after the death of Cherylee Shennan, and from the inquest was that there was no substantial interagency communication following the perpetrator's release on licence, which would, the jury found, have allowed the sharing of his licence conditions and action plans to be put in place by local police forces. The jury concluded that such a failing possibly contributed to the death on the 17th March 2014. At the inquest no evidence was heard regarding any changes to MAPPA or the guidance given. Whilst the evidence heard was that the MAPPA level allocated to an individual is fluid, and would be based upon their risks and presentation at that time, my concern centres on the issue that an offender who has served a significant sentence and accordingly has never been fully tested before release on licence, and who has a significant history of domestic abuse and violence, will still be released on MAPPA level 1 . On the evidence that was heard there remains no mandated process for joined up inter-agency working or communication at the point of their release, or when they develop new personal relationships.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 detail licence conditions during MAPPA Level 1 management
Wider context from the report “The perpetrator was managed on release at MAPPA Level 1. Following his release there were no local MAPPA 1 meetings, no inter-agency meetings and no significant inter-agency communications regarding the perpetrator, no detailing of his licence conditions , and no information regarding either his nature or the trigger factors for his offending. Evidence was heard regarding the findings of two separate reviews that took place following the death of Cherylee, and the recommendations that were made as a result of those reviews, in particular centred on the lack of inter-agency communications. My concern is that despite this, and the findings of the report, when evidence was heard regarding how systems had changed, there is still no mandatory process for the sharing of information between agencies where the offender despite a known, and extensive, history of domestic abuse and identified trigger factors, is then managed at MAPPA Level 1.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 obtain information during initial attendances on reported domestic abuse incidents
Wider context from the report “Following the death of Cherylee, her death, and actions taken in the months leading up to it were the subject of two detailed reviews. Following the Domestic Homicide Review a number of recommendations were made by the author of the Individual Management Report, Mr Gary Fishwick including concerns regarding initial grading of calls to identify initial responses, the obtaining of information as part of initial attendances on reported domestic abuse incidents and the carrying and use of personal protective equipment. Whilst the recommendations were made, Mr Fishwick could give no evidence at the inquest into the death of Cherylee to indicate whether those recommendations had in fact been actioned or not, and accordingly whether anything had changed following the death of Cherylee and the learning exercise that were subsequently undertaken.
In particular reference was made to, but unsupported by documentation, or any other form of evidence:
• Policies reflecting recommended changes;
• Information sharing agreements between agencies;
• MARAC emergency policy or notes;
• DASH Training or policy regarding obtaining GP details; and
• Audits of Grade 2 ‘Ethical fails’ and reasons for such fails.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 probation staffing capacity for complex and demanding casework
Wider context from the report “2) Evidence was further heard regarding the Report of the Chief Inspector of Probation 2019 and in particular the finding that "Many individuals were drifting through their supervision period without being challenged or supported to change their prediction for domestic abuse" and that "The number of probation professionals is now at a critical level . There is a national shortage of professional probation staff and especially those mainly responsible for more complex and demanding casework ". It was agreed by those senior probation witnesses that staffing and workloads had been an issue in this matter , as found by the jury, and furthermore continued to be so .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 evidence implementation of recommended safety changes
Wider context from the report “Following the death of Cherylee, her death, and actions taken in the months leading up to it were the subject of two detailed reviews. Following the Domestic Homicide Review a number of recommendations were made by the author of the Individual Management Report, Mr Gary Fishwick including concerns regarding initial grading of calls to identify initial responses, the obtaining of information as part of initial attendances on reported domestic abuse incidents and the carrying and use of personal protective equipment. Whilst the recommendations were made, Mr Fishwick could give no evidence at the inquest into the death of Cherylee to indicate whether those recommendations had in fact been actioned or not , and accordingly whether anything had changed following the death of Cherylee and the learning exercise that were subsequently undertaken.
In particular reference was made to, but unsupported by documentation, or any other form of evidence :
• Policies reflecting recommended changes;
• Information sharing agreements between agencies;
• MARAC emergency policy or notes;
• DASH Training or policy regarding obtaining GP details; and
• Audits of Grade 2 ‘Ethical fails’ and reasons for such fails.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 mandated joined-up inter-agency communication at offender release or when new personal relationships develop
Wider context from the report “1) During the course of the inquest statistics regarding the nature of domestic abuse were repeatedly reviewed and accepted by senior member of both probation and police services. In particular domestic abuse features in about half of all cases managed by probation staff and that in the year to the end of 2018 of the 659 homicides 1 in 10 were committed by a partner. Evidence was heard of the MAPPA process, for the managing of risk of offenders to be released on licence, and for the interagency sharing of information regarding those offenders. During the course of the evidence it was made clear that the perpetrator in this instance was a very dangerous individual, who was described as controlling and manipulative, and who, it was accepted by the witnesses involved in his management, was likely to have controlled his meetings by his nature, and by partial disclosures of information. The underlying issue that arose from both the various reviews that took place after the death of Cherylee Shennan, and from the inquest was that there was no substantial interagency communication following the perpetrator's release on licence , which would, the jury found, have allowed the sharing of his licence conditions and action plans to be put in place by local police forces. The jury concluded that such a failing possibly contributed to the death on the 17th March 2014. At the inquest no evidence was heard regarding any changes to MAPPA or the guidance given. Whilst the evidence heard was that the MAPPA level allocated to an individual is fluid, and would be based upon their risks and presentation at that time, my concern centres on the issue that an offender who has served a significant sentence and accordingly has never been fully tested before release on licence, and who has a significant history of domestic abuse and violence, will still be released on MAPPA level 1. On the evidence that was heard there remains no mandated process for joined up inter-agency working or communication at the point of their release, or when they develop new personal relationships .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Deficiencies in initial grading of calls to identify initial responses
Wider context from the report “Following the death of Cherylee, her death, and actions taken in the months leading up to it were the subject of two detailed reviews. Following the Domestic Homicide Review a number of recommendations were made by the author of the Individual Management Report, Mr Gary Fishwick including concerns regarding initial grading of calls to identify initial responses , the obtaining of information as part of initial attendances on reported domestic abuse incidents and the carrying and use of personal protective equipment. Whilst the recommendations were made, Mr Fishwick could give no evidence at the inquest into the death of Cherylee to indicate whether those recommendations had in fact been actioned or not, and accordingly whether anything had changed following the death of Cherylee and the learning exercise that were subsequently undertaken.
In particular reference was made to, but unsupported by documentation, or any other form of evidence:
• Policies reflecting recommended changes;
• Information sharing agreements between agencies;
• MARAC emergency policy or notes;
• DASH Training or policy regarding obtaining GP details; and
• Audits of Grade 2 ‘Ethical fails’ and reasons for such fails.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain mandatory inter-agency information sharing for MAPPA Level 1 management
Wider context from the report “The perpetrator was managed on release at MAPPA Level 1. Following his release there were no local MAPPA 1 meetings, no inter-agency meetings and no significant inter-agency communications regarding the perpetrator , no detailing of his licence conditions, and no information regarding either his nature or the trigger factors for his offending. Evidence was heard regarding the findings of two separate reviews that took place following the death of Cherylee, and the recommendations that were made as a result of those reviews, in particular centred on the lack of inter-agency communications . My concern is that despite this, and the findings of the report, when evidence was heard regarding how systems had changed, there is still no mandatory process for the sharing of information between agencies where the offender despite a known, and extensive, history of domestic abuse and identified trigger factors, is then managed at MAPPA Level 1.
” Open source report
16 Jul 2019 Mr Darren Keith Cumberbatch · Prevention of Future Deaths report Warwickshire
View report summary
Concerns raised 1 Lack of probation hostel staff awareness and training in relation to Acute Behavioural Disturbance View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Mr Darren Keith Cumberbatch · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mr Darren Cumberbatch became acutely agitated at a probation hostel and was taken to hospital after police used physical force, Tasers, incapacitant spray and a baton during restraint. He was treated for a suspected cocaine-related drug overdose, developed worsening kidney function and multi-organ failure, and died on 19 July 2017. The report raised concerns that probation hostel staff lacked awareness and training in Acute Behavioural Disturbance, including the importance of information sharing, de-escalation and minimising restraint.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Lack of probation hostel staff awareness and training in relation to Acute Behavioural Disturbance
Wider context from the report “v. National Probation service staff receive mandatory training which includes an aspect of substance misuse. The probation hostel staff had no awareness or training in relation to Acute Behavioural Disturbance.
vi. ABD is a potential medical emergency.
vii. Information sharing of an individual possibly suffering from ABD is very significant and those with a basic knowledge of it can be implemental in formulating a plan to manage a person suspected to be suffering with ABD which include the use of de-escalation techniques so as to minimalise the use of restraint.
viii. The police have basic training to recognise the signs / symptoms which can dictate as to how an individual is managed, in particular with regards to restraint (detain/ contain rather than restraint).
ix. West Midlands Ambulance call assessors receive information to determine the appropriate level of care at the point of a telephone call to the ambulance service. A patient suspected to be suffering with “ABD” is automatically a ‘category 2’ situation i.e. a potentially serious condition that may require rapid assessment with a response target time frame of 18 minutes.
x. Basic training for probation hostel staff (e.g. similar to simple basic training materials that are provided to the police by the college of policing to increase awareness of ABD) is possible and this may prevent future deaths. Such awareness combined with opportunities to engage with an individual and a familiarisation with residents may better aid in the de-escalation of a person suspected to be suffering with ABD and thereby potentially minimalizing the necessity to resort to any restraint (which can be very dangerous to a person suffering since restraint and struggle against restraint increases the acidosis in the body which can lead to muscle breakdown which can lead to rhabdomyolysis and multi organ failure). It may best facilitate the individual engaging willingly seeking the necessary medical attention.
” 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 Assess the most appropriate acute behavioural disturbance awareness training package for approved premises staff.
Verbatim wording from the response “In response to your recommendation I confirm that the National Probation Service now has plans in place to assess the most appropriate training package to meet this training requirement and to develop an implementation plan across the whole approved premises estate with the intention to start the roll out of ABD awareness training early in 2020.” Source location 2019-0289-Response-by-HM-Prison-Probation-Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop an implementation plan for acute behavioural disturbance awareness training across the approved premises estate.
Verbatim wording from the response “In response to your recommendation I confirm that the National Probation Service now has plans in place to assess the most appropriate training package to meet this training requirement and to develop an implementation plan across the whole approved premises estate with the intention to start the roll out of ABD awareness training early in 2020.” Source location 2019-0289-Response-by-HM-Prison-Probation-Service
Open published response
21 Jun 2019 Ryan Stephen TRIMMER · Prevention of Future Deaths report East Sussex
View report summary
Concerns raised 2 Failure of the ACCT process to provide effective reviews View source Lack of first aid training for frontline prison staff View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Ryan Stephen TRIMMER · 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 Trimmer was remanded to HMP Lewes on 4 March 2017, had a history of self-harm and suicide attempts, and was found hanging in his cell on 22 April; he died in hospital on 26 April 2017. The inquest identified inadequate ACCT reviews as a matter that caused or contributed to his death. The report also raised concerns about prison staff resourcing on the healthcare wing and the lack of first-aid training among some frontline 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 of the ACCT process to provide effective reviews
Wider context from the report “The ACCT process was ineffective. They jury made a factual finding of inadequate ACCT reviews . The Court heard evidence of the ACCT Pilot Scheme underway in certain other prisons. HMP Lewes should be considered as a priority facility for future extension of the ACCT Pilot Scheme.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 first aid training for frontline prison staff
Wider context from the report “Prison staff are often first responders to medical emergencies of prisoners, but not all have received first aid training . One frontline prison staff member gave evidence that he had not received training in 16 years of working for HMPS and felt he needed refresher training.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the provision of first aid in prisons.
Verbatim wording from the response “At a national level, since 2016 all new prison officers have completed a mandatory level 3 qualification in Emergency First Aid at Work as part of their Prison Officer Entry Level Training. This includes the application of CPR and the use of a defibrillator. Whilst there is currently no national requirement for all prison staff to be trained in first aid, we are currently reviewing the provision of first aid in prison, and we expect this to result in revisions to first aid policy and training. We have also been working with the Awarding Body on the development of a custodial First Aid awareness course, focusing on key areas and situations that may arise in the prison environment.” Source location 2019-0215-Response-by-HM-Prison-and-Probabtion-Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce a one-day first aid refresher course to maintain staff training levels.
Verbatim wording from the response “Two on-site first aid trainers will be delivering first aid training to staff as part of the prison’s monthly training provision, and a one-day refresher course will be introduced to ensure that training levels are maintained. Custodial Managers (the most senior uniformed grade of staff) and Officer Support Grades (staff that support the duties of Prison Officers) have been provided with this training first, in order to ensure that those covering the Orderly Officer role” Source location 2019-0215-Response-by-HM-Prison-and-Probabtion-Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver monthly first aid training to prison staff through two on-site trainers.
Verbatim wording from the response “Two on-site first aid trainers will be delivering first aid training to staff as part of the prison’s monthly training provision, and a one-day refresher course will be introduced to ensure that training levels are maintained. Custodial Managers (the most senior uniformed grade of staff) and Officer Support Grades (staff that support the duties of Prison Officers) have been provided with this training first, in order to ensure that those covering the Orderly Officer role” Source location 2019-0215-Response-by-HM-Prison-and-Probabtion-Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a custodial First Aid awareness course with the awarding body.
Verbatim wording from the response “At a national level, since 2016 all new prison officers have completed a mandatory level 3 qualification in Emergency First Aid at Work as part of their Prison Officer Entry Level Training. This includes the application of CPR and the use of a defibrillator. Whilst there is currently no national requirement for all prison staff to be trained in first aid, we are currently reviewing the provision of first aid in prison, and we expect this to result in revisions to first aid policy and training. We have also been working with the Awarding Body on the development of a custodial First Aid awareness course, focusing on key areas and situations that may arise in the prison environment.” Source location 2019-0215-Response-by-HM-Prison-and-Probabtion-Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require new prison officers to complete mandatory level 3 Emergency First Aid at Work training, including CPR and defibrillator use.
Verbatim wording from the response “At a national level, since 2016 all new prison officers have completed a mandatory level 3 qualification in Emergency First Aid at Work as part of their Prison Officer Entry Level Training. This includes the application of CPR and the use of a defibrillator. Whilst there is currently no national requirement for all prison staff to be trained in first aid, we are currently reviewing the provision of first aid in prison, and we expect this to result in revisions to first aid policy and training. We have also been working with the Awarding Body on the development of a custodial First Aid awareness course, focusing on key areas and situations that may arise in the prison environment.” Source location 2019-0215-Response-by-HM-Prison-and-Probabtion-Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Evaluate the revised ACCT pilot to inform development of a new national process.
Verbatim wording from the response “I note the findings of the jury with regard to the operation of the ACCT process in this case, and it is good to know that you heard evidence about the pilot of the revised version of ACCT. This took place in nine prisons and one immigration removal centre from February to June 2019. The feedback from the sites has been positive, and a formal evaluation of the pilot is currently being undertaken. The findings will inform the development of a new version of ACCT that we intend to roll out nationally in early 2020. In support of this roll out there will be a clear communication strategy, and support mechanisms will be in place to help embed the revised process within each site. It is too early to give a firm date for the new process to be introduced at HMP Lewes, but we have noted your view that this should be a priority.” Source location 2019-0215-Response-by-HM-Prison-and-Probabtion-Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Roll out the revised ACCT process nationally, supported by communications and site-level implementation support.
Verbatim wording from the response “I note the findings of the jury with regard to the operation of the ACCT process in this case, and it is good to know that you heard evidence about the pilot of the revised version of ACCT. This took place in nine prisons and one immigration removal centre from February to June 2019. The feedback from the sites has been positive, and a formal evaluation of the pilot is currently being undertaken. The findings will inform the development of a new version of ACCT that we intend to roll out nationally in early 2020. In support of this roll out there will be a clear communication strategy, and support mechanisms will be in place to help embed the revised process within each site. It is too early to give a firm date for the new process to be introduced at HMP Lewes, but we have noted your view that this should be a priority.” Source location 2019-0215-Response-by-HM-Prison-and-Probabtion-Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide priority first aid training to Custodial Managers and Officer Support Grades.
Verbatim wording from the response “Two on-site first aid trainers will be delivering first aid training to staff as part of the prison’s monthly training provision, and a one-day refresher course will be introduced to ensure that training levels are maintained. Custodial Managers (the most senior uniformed grade of staff) and Officer Support Grades (staff that support the duties of Prison Officers) have been provided with this training first, in order to ensure that those covering the Orderly Officer role” Source location 2019-0215-Response-by-HM-Prison-and-Probabtion-Service
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing arrangements require sufficient first-aid-trained staff on duty, with at least two nurses and one trained prison staff member available at HMP Lewes.
Verbatim wording from the response “Your second concern is that whilst prison staff can often be first on scene at a medical emergency, not all have received training in first aid. The Governors of each prison are required to ensure that there are sufficient numbers of staff trained in first aid on duty, and at HMP Lewes at least two trained nurses and one trained member of prison staff are available at all times.” Source location 2019-0215-Response-by-HM-Prison-and-Probabtion-Service
Open published response
Concerns raised 9 Probation staffing and accommodation deficiencies View source Lack of integrated information technology View source Insufficient time and unsuitable environment for meaningful probation engagement View source Lack of contemporaneous probation computer records View source Over-reliance on offender self-reporting and ineffective challenge of accounts View source Failure to complete timely OASys risk and needs assessments View source Failure to share relevant police information with Probation View source Failures of communication across relevant sources View source Failure to monitor and actively manage Category 2 Level 1 offenders View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Miss Nguyen Ngoc Quyen · 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
Miss Nguyen Ngoc Quyen died on 15 August 2017 at Success Road, Shiney Row, Houghton Le Spring; her death was consistent with the effects of fire. The report identified concerns about failures to act sufficiently, promptly and in a coordinated manner on known breaches of life licence conditions, including failures in information sharing between the Police and Probation Service, alongside wider organisational and supervision failings.
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 Probation staffing and accommodation deficiencies
Wider context from the report “The Inquest highlighted many other issues: -
• The Probation Service in Sunderland had staffing and accommodation problems. Operations and efficiency appeared to be in stark contrast between North West and North East.
• The time spent with ████████ was short and in a working environment not conducive to meaningful engagement.
• Unwin undermined the supervisory process by attending appointments with his child and not progressing in a more timely way the request to create a portfolio of his employment, culminating in an unsigned reference dated 25th July 2017.
• There were no contemporaneous computer records from 13th December 2016 until 18th August 2017, the day before ████████ appeared in Court for murder.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 integrated information technology
Wider context from the report “However, I remain concerned. For example, Probation were of the view that the present solution was an interim one, whereas the Police thought it was finalised.
There were further issues considered, such as the lack of integrated IT , failures of communication from a number of sources, supervision, issues of risk management and staff turnover, and pressures upon staff performance and the ability to investigate self-report.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 time and unsuitable environment for meaningful probation engagement
Wider context from the report “The Inquest highlighted many other issues: -
• The Probation Service in Sunderland had staffing and accommodation problems. Operations and efficiency appeared to be in stark contrast between North West and North East.
• The time spent with ████████ was short and in a working environment not conducive to meaningful engagement.
• Unwin undermined the supervisory process by attending appointments with his child and not progressing in a more timely way the request to create a portfolio of his employment, culminating in an unsigned reference dated 25th July 2017.
• There were no contemporaneous computer records from 13th December 2016 until 18th August 2017, the day before ████████ appeared in Court for murder.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 contemporaneous probation computer records
Wider context from the report “The Inquest highlighted many other issues: -
• The Probation Service in Sunderland had staffing and accommodation problems. Operations and efficiency appeared to be in stark contrast between North West and North East.
• The time spent with ████████ was short and in a working environment not conducive to meaningful engagement.
• Unwin undermined the supervisory process by attending appointments with his child and not progressing in a more timely way the request to create a portfolio of his employment, culminating in an unsigned reference dated 25th July 2017.
• There were no contemporaneous computer records from 13th December 2016 until 18th August 2017 , the day before ████████ appeared in Court for murder.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Over-reliance on offender self-reporting and ineffective challenge of accounts
Wider context from the report “There was an over reliance on self-reporting by the offenders. The evidence exposed a system for the protection of the public, which was at times dysfunctional, contributed to by human factors.
Evidence heard during the hearings demonstrated that there was a disconnect between the reality on the ground and, in particular, ████████’s accounts to his Probation Officer. Although inevitably he would minimise his actions, there was little or no evidence that he was challenged effectively .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 timely OASys risk and needs assessments
Wider context from the report “On the evidence, there were multiple occasions when information about ████████ could and should have been shared between the Police and Probation, and for him to be challenged in a more meaningful way than he was.
A Probation expert gave evidence about:
• the limitations of what can be achieved through the supervisory process;
• the frequency of the assessments in relation to ████████ appear to “have fallen below good practice standards” but had further reviews taken place, the risk assessments would not have changed;
• the absence of an Offender Assessment System (OASys) assessment on ████████ for over 3 years fell below good practice . Such an assessment would have assessed the risks and needs of an Offender;
• if Northumbria Police had passed on information to Probation about 2 incidents involving ████████ there would have been enforcement action, but short of recall as the threshold criteria had not been met.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 police information with Probation
Wider context from the report “In April 2015 due to high operational demand there was a direction from the senior management team of Northumbria Police to stop monitoring Category 2 Level 1 offenders and to remove the markers on the log. As a result, the Multi Agency Public Protection Arrangements (MAPPA) department were no longer actively managing Category 2 Level 1 offenders. The responsibility for sharing information was solely with the sourcing officer. With ████████ his Police computer record was not updated , and attending Police Officers for incidents in 2015 and 2017 did not pass information to the relevant Probation Officer .
The responsibility goes wider though to Control Room Staff, Patrol Sergeants, Patrol Constables and Supervising Sergeants too, when markers, flags and warnings were evident.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failures of communication across relevant sources
Wider context from the report “However, I remain concerned. For example, Probation were of the view that the present solution was an interim one, whereas the Police thought it was finalised.
There were further issues considered, such as the lack of integrated IT, failures of communication from a number of sources , supervision, issues of risk management and staff turnover, and pressures upon staff performance and the ability to investigate self-report.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 monitor and actively manage Category 2 Level 1 offenders
Wider context from the report “In April 2015 due to high operational demand there was a direction from the senior management team of Northumbria Police to stop monitoring Category 2 Level 1 offenders and to remove the markers on the log . As a result, the Multi Agency Public Protection Arrangements (MAPPA) department were no longer actively managing Category 2 Level 1 offenders . The responsibility for sharing information was solely with the sourcing officer. With ████████ his Police computer record was not updated, and attending Police Officers for incidents in 2015 and 2017 did not pass information to the relevant Probation Officer.
The responsibility goes wider though to Control Room Staff, Patrol Sergeants, Patrol Constables and Supervising Sergeants too, when markers, flags and warnings were evident.
” 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 Carry out a recruitment drive and training programme to increase the number of qualified probation officers and fill current vacancies.
Verbatim wording from the response “The Transforming Rehabilitation Programme (implemented from 1st June 2014) resulted in a number of resource issues, which have been widely recognised and acknowledged. These issues have been taken into consideration in the planning of further structural changes to reunify all offender management into the NPS. At the heart of this is a robust recruitment drive and training programme to increase the number of qualified probation officers in the expectation that by the end of 2021 the current vacancies in the NPS will be filled. Alongside this is a review of required office space and the” Source location 2019-0194-Response-by-HM-Prison-and-Probation-Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Roll out the national Supervision and Line Management Framework across National Probation Service divisions, including required supervision meetings, practice observations and recording of challenged decisions.
Verbatim wording from the response “To better support front line probation staff in the effectiveness of their supervision of offenders a new national Supervision and Line Management Framework has been developed and is being rolled out across the NPS Divisions during 2019. This work forms part of the National Probation Service 2020 Change Programme and has been developed using ideas and evidence from the Skills for Effective Engagement Development and Supervision Programme (SEEDS). This Framework is designed to ensure a consistent and appropriate level of management oversight through practice supervision sessions and observation of practice. Through observation of practice senior probation officers will be able to see whether staff are being sufficiently challenging and adopting a properly investigative approach in their face to face supervision of the offender.” Source location 2019-0194-Response-by-HM-Prison-and-Probation-Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review required office space to support delivery of a high-quality probation service.
Verbatim wording from the response “The Transforming Rehabilitation Programme (implemented from 1st June 2014) resulted in a number of resource issues, which have been widely recognised and acknowledged. These issues have been taken into consideration in the planning of further structural changes to reunify all offender management into the NPS. At the heart of this is a robust recruitment drive and training programme to increase the number of qualified probation officers in the expectation that by the end of 2021 the current vacancies in the NPS will be filled. Alongside this is a review of required office space and the” Source location 2019-0194-Response-by-HM-Prison-and-Probation-Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate Lifer Review Panels to provide senior oversight and scrutiny of risk assessments and progress for supervised life-sentence offenders.
Verbatim wording from the response “This framework sits alongside the new Lifer Review Panels, which were outlined at the Inquest. The aim of these Panels is to ensure Heads of Local Delivery Units have oversight of the lifer cohort under their responsibility and to scrutinise the robustness of the risk assessment/progress of life sentence offenders subject to supervision in their area. An initial lifer panel review will be completed within three months of release and annual reviews will take place thereafter. In preparation for Panel meetings, the offender manager is required to review OASys and the offender manager uses the review as a discussion topic with the lifer to gain their perspective on progress to date. The offender manager and Scottish Probation Officer discuss lifer cases in supervision prior to the Panel meeting and undertake appropriate manager oversight recording in NDElius.” Source location 2019-0194-Response-by-HM-Prison-and-Probation-Service
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing Northumbria Constabulary information-sharing steps are accepted by MAPPA and NPS representatives as a permanent solution at this time.
Verbatim wording from the response “The regulation 28 report acknowledges that some of the issues identified by the investigation into the death have already been addressed by Northumbria Constabulary. However, you raised concern that actions taken provided an interim rather than a permanent solution. By way of confirmation, I have set out below in an addendum to this response, the actions I am advised have been taken by Northumbria Constabulary and am able to confirm that these steps are acknowledged and accepted by the MAPPA representatives and Heads of Service in the NPS North East Division in both the North of Tyne and South of Tyne Local Delivery Units as being correct and a permanent solution at this time.” Source location 2019-0194-Response-by-HM-Prison-and-Probation-Service
Open published response
16 May 2019 Daniel Davey · Prevention of Future Deaths report Oxfordshire
View report summary
Concerns raised 5 Failure of prison and healthcare staff to jointly manage in-possession medication risks and intervene promptly View source Failure to ensure healthcare attendance or input at ACCT reviews View source Inadequate advance notification and information sharing for ACCT reviews View source Failure to review in-possession medication risk assessments when risk changes View source Inadequate cell searching and collection of in-possession medication after a change of risk View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Daniel Davey · 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
Daniel Davey, aged 21, died at John Radcliffe Hospital on 12 January 2018 after deliberately overdosing on propranolol in his cell at HMP Bullingdon Prison. The report raises concerns about healthcare attendance at ACCT reviews, risk assessments and management of in-possession medication, cell searches, and failures to share and act on information relevant to his safety.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure of prison and healthcare staff to jointly manage in-possession medication risks and intervene promptly
Wider context from the report “2. Reviews of ‘in possession’ medication risk assessments – The second concern also relates to prison and healthcare. In particular, it relates to a prisoner placed on an ACCT. I heard evidence that, initially, a template is used at the reception healthcare screen to determine if medication should be held in possession or not. I was told that, now, this is subsequently reviewed by the prescriber and, on opening an ACCT, there is an automatic review of the risk assessment in accordance with CUK’s new policy.
In the case of Mr Davey, there was an initial risk assessment at reception and he was deemed suitable for in possession medication, but this was not reviewed when he was subsequently placed on the 2 ACCT documents in December and January or when he disclosed to a mental health nurse on 29 December that he had a plan to kill himself. I understand that new systems are in place (with healthcare) but it would be reassuring if there is a system of audit to ensure compliance, namely, that the in possession risk assessments are reviewed. I appreciate a review might not necessarily result in medication being taken away. I also appreciate this is a difficult area in view of patient confidentiality and, of course, the danger that a prisoners physical or mental health could be put at risk if medication is taken away.
A related concern is the fact that prison officers did not appear to have in mind the risks associated with in possession medication . It appeared to be disregarded because it was information that was not available to them and it was therefore deemed a matter for healthcare. I am concerned that there is a danger in leaving the issue of in possession medication solely to healthcare. There could be a time delay of several hours or even longer between a prisoner having a mental health crisis and healthcare involvement/reassessment . It appears there needs to be joint liaison between the ACCT case manager and healthcare and a plan to intervene and remove medicine if necessary .
This leads to a final related concern. There is the question of cell searches for stockpiled medication and the collection of properly held in possession medication when there is a change of risk such as an ACCT document being opened. I did not hear much evidence about practice or policies relating to searching and potentially removing medication. This is clearly a task that rests with prison staff and it would be helpful to have further information about this.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 healthcare attendance or input at ACCT reviews
Wider context from the report “1. Healthcare attendance at ACCT reviews – This concern relates to both the prison and healthcare. It was clear from evidence from prison and healthcare staff that it was not routine for healthcare to attend ACCT reviews . This is a significant concern and it is not in accordance with local and national policy. I understand that there were occasions when prison staff requested healthcare attendance, but no one was available . The system of providing advance notification to healthcare about the date of ACCT reviews was not comprehensive. It resulted in ACCT reviews, as in this case, taking place without information being available to the assessor/reviewer. For example, information about suicidal ideation/attempts and other information disclosed to healthcare and also information about ‘in possession medication’. Encouragingly, the evidence from prison and healthcare staff was that ACCT reviews no longer take place without healthcare attendance and/or input (perhaps over the telephone). It would be helpful if there could be a further level of reassurance provided, firstly, communications between prison and healthcare staff in the conduct of ACCT reviews and, secondly, a process of auditing ACCT reviews in order to pick up cases where there is no healthcare input.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 advance notification and information sharing for ACCT reviews
Wider context from the report “1. Healthcare attendance at ACCT reviews – This concern relates to both the prison and healthcare. It was clear from evidence from prison and healthcare staff that it was not routine for healthcare to attend ACCT reviews. This is a significant concern and it is not in accordance with local and national policy. I understand that there were occasions when prison staff requested healthcare attendance, but no one was available. The system of providing advance notification to healthcare about the date of ACCT reviews was not comprehensive . It resulted in ACCT reviews, as in this case, taking place without information being available to the assessor/reviewer . For example, information about suicidal ideation/attempts and other information disclosed to healthcare and also information about ‘in possession medication’. Encouragingly, the evidence from prison and healthcare staff was that ACCT reviews no longer take place without healthcare attendance and/or input (perhaps over the telephone). It would be helpful if there could be a further level of reassurance provided, firstly, communications between prison and healthcare staff in the conduct of ACCT reviews and, secondly, a process of auditing ACCT reviews in order to pick up cases where there is no healthcare input.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to review in-possession medication risk assessments when risk changes
Wider context from the report “2. Reviews of ‘in possession’ medication risk assessments – The second concern also relates to prison and healthcare. In particular, it relates to a prisoner placed on an ACCT. I heard evidence that, initially, a template is used at the reception healthcare screen to determine if medication should be held in possession or not. I was told that, now, this is subsequently reviewed by the prescriber and, on opening an ACCT, there is an automatic review of the risk assessment in accordance with CUK’s new policy.
In the case of Mr Davey, there was an initial risk assessment at reception and he was deemed suitable for in possession medication, but this was not reviewed when he was subsequently placed on the 2 ACCT documents in December and January or when he disclosed to a mental health nurse on 29 December that he had a plan to kill himself . I understand that new systems are in place (with healthcare) but it would be reassuring if there is a system of audit to ensure compliance, namely, that the in possession risk assessments are reviewed . I appreciate a review might not necessarily result in medication being taken away. I also appreciate this is a difficult area in view of patient confidentiality and, of course, the danger that a prisoners physical or mental health could be put at risk if medication is taken away.
A related concern is the fact that prison officers did not appear to have in mind the risks associated with in possession medication. It appeared to be disregarded because it was information that was not available to them and it was therefore deemed a matter for healthcare. I am concerned that there is a danger in leaving the issue of in possession medication solely to healthcare. There could be a time delay of several hours or even longer between a prisoner having a mental health crisis and healthcare involvement/reassessment. It appears there needs to be joint liaison between the ACCT case manager and healthcare and a plan to intervene and remove medicine if necessary.
This leads to a final related concern. There is the question of cell searches for stockpiled medication and the collection of properly held in possession medication when there is a change of risk such as an ACCT document being opened. I did not hear much evidence about practice or policies relating to searching and potentially removing medication. This is clearly a task that rests with prison staff and it would be helpful to have further information about this.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 cell searching and collection of in-possession medication after a change of risk
Wider context from the report “2. Reviews of ‘in possession’ medication risk assessments – The second concern also relates to prison and healthcare. In particular, it relates to a prisoner placed on an ACCT. I heard evidence that, initially, a template is used at the reception healthcare screen to determine if medication should be held in possession or not. I was told that, now, this is subsequently reviewed by the prescriber and, on opening an ACCT, there is an automatic review of the risk assessment in accordance with CUK’s new policy.
In the case of Mr Davey, there was an initial risk assessment at reception and he was deemed suitable for in possession medication, but this was not reviewed when he was subsequently placed on the 2 ACCT documents in December and January or when he disclosed to a mental health nurse on 29 December that he had a plan to kill himself. I understand that new systems are in place (with healthcare) but it would be reassuring if there is a system of audit to ensure compliance, namely, that the in possession risk assessments are reviewed. I appreciate a review might not necessarily result in medication being taken away. I also appreciate this is a difficult area in view of patient confidentiality and, of course, the danger that a prisoners physical or mental health could be put at risk if medication is taken away.
A related concern is the fact that prison officers did not appear to have in mind the risks associated with in possession medication. It appeared to be disregarded because it was information that was not available to them and it was therefore deemed a matter for healthcare. I am concerned that there is a danger in leaving the issue of in possession medication solely to healthcare. There could be a time delay of several hours or even longer between a prisoner having a mental health crisis and healthcare involvement/reassessment. It appears there needs to be joint liaison between the ACCT case manager and healthcare and a plan to intervene and remove medicine if necessary.
This leads to a final related concern. There is the question of cell searches for stockpiled medication and the collection of properly held in possession medication when there is a change of risk such as an ACCT document being opened . I did not hear much evidence about practice or policies relating to searching and potentially removing medication . This is clearly a task that rests with prison staff and it would be helpful to have further information about this.
” 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 Distribute a safety briefing on in-possession medication risks and required action during fabric checks or cell searches to all staff.
Verbatim wording from the response “Lastly, you asked about the policy for cell searches for stockpiled medication. The safer custody department has distributed a safety briefing on in possession medication to all staff to ensure that they are aware of the risks and know what action to take if they discover unusual amounts of in possession medication when conducting fabric checks or cell searches. In future, the issue of stockpiled medication will also be covered in the local ACCT case manager training so that, when immediate actions plans are completed, consideration is given to the need to check for and remove in possession medication as a temporary measure before a full assessment and review has taken place.” Source location 2019-0267-Response-by-HM-Prison-Probation-Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce and embed electronic quality-assurance checks covering healthcare attendance at ACCT reviews by the end of August 2019.
Verbatim wording from the response “New electronic quality assurance checks are to be introduced and embedded by the end of August 2019, and these will include checking healthcare attendance at reviews. In the meantime, the safer custody department is performing spot checks to monitor progress.” Source location 2019-0267-Response-by-HM-Prison-Probation-Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue guidance requiring ACCT case managers to discuss in-possession medication routinely and complete risk assessments with healthcare input.
Verbatim wording from the response “Your second concern relates to reviews of in possession medication risk assessments. I understand Care UK and Midlands Partnership NHS Foundation Trust will be replying to you separately on this point. At Bullingdon, if the ACCT case manager is concerned about the immediate welfare of an individual they are required to conduct a review immediately, and to ensure that there is healthcare input to that review. The prison has issued guidance to all case managers stating that in possession medication is one of the topics that should routinely be discussed in ACCT reviews, and that a risk assessment must be conducted, informed by the advice of healthcare staff. If this advice is not immediately available then ACCT case managers can at their discretion remove in possession medication until they can confirm that it is safe for the prisoner to continue to have it in their own possession.” Source location 2019-0267-Response-by-HM-Prison-Probation-Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Include stockpiled medication and temporary removal considerations in future local ACCT case-manager training.
Verbatim wording from the response “Lastly, you asked about the policy for cell searches for stockpiled medication. The safer custody department has distributed a safety briefing on in possession medication to all staff to ensure that they are aware of the risks and know what action to take if they discover unusual amounts of in possession medication when conducting fabric checks or cell searches. In future, the issue of stockpiled medication will also be covered in the local ACCT case manager training so that, when immediate actions plans are completed, consideration is given to the need to check for and remove in possession medication as a temporary measure before a full assessment and review has taken place.” Source location 2019-0267-Response-by-HM-Prison-Probation-Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the revised ACCT form and guidance nationally during 2020.
Verbatim wording from the response “At national level we are working to improve the ACCT case management system and piloted a new version of the form and associated guidance in ten prisons during the spring of 2019. We realise the importance of the healthcare contribution to ACCT, and NHS England, and their Welsh equivalents, have been involved in this pilot project. The revised form and guidance are clearer about the expectations of healthcare staff. We are currently evaluating the pilot and plan to implement the new model nationally during 2020. We will ensure that the learning from this case is used to inform the development of the materials that are used to inform the national roll out of the new model.” Source location 2019-0267-Response-by-HM-Prison-Probation-Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor healthcare attendance at ACCT reviews through safer-custody spot checks pending implementation of electronic quality-assurance checks.
Verbatim wording from the response “New electronic quality assurance checks are to be introduced and embedded by the end of August 2019, and these will include checking healthcare attendance at reviews. In the meantime, the safer custody department is performing spot checks to monitor progress.” Source location 2019-0267-Response-by-HM-Prison-Probation-Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Embed the new ACCT case-management process, including dedicated case managers, review booking oversight and daily healthcare attendance allocation.
Verbatim wording from the response “In June 2019, a new way of operating the ACCT case management system was implemented at Bullingdon, with a specific case manager being allocated to each ACCT case. This system allows ACCT reviews to be booked by the case managers on a spreadsheet that is overseen by the safer custody department. Reviews can be organised earlier through this booking system, giving healthcare better capability to ensure attendance at all reviews, and each day an identified member of healthcare staff is responsible for attending each review or allocating an attendee to go in their place. If there are any issues with healthcare attendance, case managers are asked to inform the safer custody department and remedial action is taken.” Source location 2019-0267-Response-by-HM-Prison-Probation-Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Evaluate the piloted revised ACCT form and guidance, incorporating healthcare expectations and learning from Mr Davey’s case.
Verbatim wording from the response “At national level we are working to improve the ACCT case management system and piloted a new version of the form and associated guidance in ten prisons during the spring of 2019. We realise the importance of the healthcare contribution to ACCT, and NHS England, and their Welsh equivalents, have been involved in this pilot project. The revised form and guidance are clearer about the expectations of healthcare staff. We are currently evaluating the pilot and plan to implement the new model nationally during 2020. We will ensure that the learning from this case is used to inform the development of the materials that are used to inform the national roll out of the new model.” Source location 2019-0267-Response-by-HM-Prison-Probation-Service
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Care UK and Midlands Partnership NHS Foundation Trust are responsible for replying about in-possession medication risk-assessment reviews.
Verbatim wording from the response “Your second concern relates to reviews of in possession medication risk assessments. I understand Care UK and Midlands Partnership NHS Foundation Trust will be replying to you separately on this point. At Bullingdon, if the ACCT case manager is concerned about the immediate welfare of an individual they are required to conduct a review immediately, and to ensure that there is healthcare input to that review. The prison has issued guidance to all case managers stating that in possession medication is one of the topics that should routinely be discussed in ACCT reviews, and that a risk assessment must be conducted, informed by the advice of healthcare staff. If this advice is not immediately available then ACCT case managers can at their discretion remove in possession medication until they can confirm that it is safe for the prisoner to continue to have it in their own possession.” Source location 2019-0267-Response-by-HM-Prison-Probation-Service
Open published response
2 Apr 2019 Tarek Mahmood CHOWDHURY · Prevention of Future Deaths report West London
View report summary
Concerns raised 4 Inadequate operation of SystmOne when new detainees arrive at IRCs View source Failure to share prisoner information between HMPPS, DEPMU and IRC staff View source Inadequate training of nurses on SystmOne and related access issues View source Failure of the process authorising IRC nurses to access former prisoners’ records 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
Tarek Mahmood CHOWDHURY · 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
Tarek Mahmood CHOWDHURY was beaten to death by another detainee while detained at Heathrow Immigration Removal Centre on 1 December 2016. The report identified concerns about information sharing between prisons, the Home Office and immigration removal centres, including the availability of intelligence and other records. It also identified concerns about access to and operation of SystmOne healthcare records during the initial screening of detainees transferred from prison.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Inadequate operation of SystmOne when new detainees arrive at IRCs
Wider context from the report “(2) That SystmOne is not operating adequately when new detainees arrive at IRCs . There are concerns both about the technology itself of SystmOne ; about the process of authorising a nurse in an IRC to see records of a former prisoner; and about whether trainers are able adequately to train nurses in respect of these issues. These concerns are addressed to NHS England, which is understood to commission and supply SystmOne; and to TPP, which is the technology company which is understood to have developed SystmOne.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 prisoner information between HMPPS, DEPMU and IRC staff
Wider context from the report “(1) That there is a failure to share information about prisoners who are to become detainees, between HMPPS and the Home Office’s DEPMU, and between HMPPS and staff in IRCs . The rolling out of Mercury intelligence to DEPMU/IRCs will not solve this problem if other information (in particular NOMIS and OASYS) is still not available to DEPMU/IRCs . This concern is addressed both to the Ministry of Justice (HMPPS) and to the Home Office (DEPMU/IRCs).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Inadequate training of nurses on SystmOne and related access issues
Wider context from the report “(2) That SystmOne is not operating adequately when new detainees arrive at IRCs. There are concerns both about the technology itself of SystmOne; about the process of authorising a nurse in an IRC to see records of a former prisoner; and about whether trainers are able adequately to train nurses in respect of these issues . These concerns are addressed to NHS England, which is understood to commission and supply SystmOne; and to TPP, which is the technology company which is understood to have developed SystmOne.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 process authorising IRC nurses to access former prisoners’ records
Wider context from the report “(2) That SystmOne is not operating adequately when new detainees arrive at IRCs. There are concerns both about the technology itself of SystmOne; about the process of authorising a nurse in an IRC to see records of a former prisoner ; and about whether trainers are able adequately to train nurses in respect of these issues. These concerns are addressed to NHS England, which is understood to commission and supply SystmOne; and to TPP, which is the technology company which is understood to have developed SystmOne.
” Open source report
21 Mar 2019 John Wright · Prevention of Future Deaths report Oxfordshire
View report summary
Concerns raised 3 Failure of the pre-arrival process to ensure receipt of high-risk self-harm or suicide information View source Lack of guidance for reducing observations of newly arrived prisoners from constant watch View source Failure to ensure that reception staff have access to all available prisoner information View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
John Wright · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
John Wright, aged 32, died at Bullingdon Prison on 15 December 2017 after being found partially suspended by an electrical cable in his cell. He had expressed suicidal thoughts and had previously been kept on constant watch, but observations were reduced to twice hourly during reception. The concerns relate to the receipt and sharing of information about heightened suicide risk and the guidance and decision-making processes for reducing observation levels.
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 pre-arrival process to ensure receipt of high-risk self-harm or suicide information
Wider context from the report “The first concern which I raise applies to both the prison and healthcare and relates to the receipt of information by the prison and/or healthcare about a heightened risk of self-harm/suicide for a prisoner who has yet to arrive at prison. I heard evidence that it is not uncommon for outside agencies to pass on concerns, and, for example, copies of relevant mental health assessments, in anticipation of the prisoner arriving at the prison in a state of heightened risk requiring help and assessment. I also heard evidence that the software system operated by healthcare (System One) does not enable healthcare staff to make entries prior to the prisoner being received at reception and a prison officer opening a record on the computer and allocating a prisoner number . This being the case, I understand that the practice has been to email or print a hard copy of the document and take it to reception . In this case, a mental health nurse who was part of the secondary mental health team received a report about heightened risk and telephoned the nurse in reception to pass on details. The secondary mental health nurse said in evidence she would normally take a hard copy of the mental health assessment that she received and place it in a tray in reception. There was an alternative of emailing, but this was not considered the best way to bring it to the attention of the relevant healthcare staff in reception.
Of course, information about an incoming prisoner, who is assessed at high risk of suicide, is precisely the sort of important information which should not be allowed to fall through any gaps. It is high priority. An outside person or agency has considered it necessary to bring the matter to the attention of the prison or health care.
I understand that Care UK have set up a generic email address for healthcare staff in reception which may assist. Clearly, this still relies on healthcare staff checking to see if any such emails have been received . I appreciate that it is very busy in reception in the late afternoon/early evening.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance for reducing observations of newly arrived prisoners from constant watch
Wider context from the report “The second matter I wish to raise, also to the prison and healthcare, is in relation to the level of observations. I heard evidence that this is often a joint responsibility held by the prison and healthcare. In this case, Mr Wright had been on constant watch, but a decision was taken during the reception process to step down to twice hourly observations. Given that staff may not have access to all available information in those first few hours, and the fact that there will not have been an opportunity for a prisoner to be observed over a significant period of time, and the fact that a more detailed assessment will not have taken place yet, there should in my view be some guidance to staff when reducing observations from constant watch .
I note that the Prison and Probation Ombudsman stated at the beginning of her report that ……. ‘Mr Wright had been under constant watch by police and court staff because he said he wanted to take his life at the earliest opportunity. Although prison staff started suicide and self-harm prevention procedures when Mr Wright arrived at Bullingdon, they reduced the level of observations from constant to twice an hour. In my view, this decision was misjudged and taken far too quickly, without a proper assessment of Mr Wright’s risk.’
I appreciate there is a great deal of responsibility on prison and healthcare staff when making assessments. Much depends on how they assess the prisoner in front of them. It may be appropriate to reduce a newly arrived prisoner from constant cell watch to less frequent observations on occasions. The concern which I raise relates to such decisions being made in reception and I enquire if there should be some guidance available to assist staff in their decision-making process? For example, should such a decision be postponed until a further assessment has been carried out the following day?
I realise that this issue is not straightforward and there are significant resource implications in keeping a prisoner under constant watch.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 reception staff have access to all available prisoner information
Wider context from the report “There is a related concern about the availability and sharing of such information or documentation amongst prison or health care staff in reception. From the evidence I heard at inquest, it appeared to me that the system for ensuring the staff in reception have access to all available information is in need of improvement . The senior prison officer in this case did not have all relevant information and she said that, if she had, there may have potentially been a different decision (I understand her to mean that Mr Wright may have remained on constant cell watch). I understand the Governor has created a position of ‘Head of Early Days’ and a system is in place to improve the process of documentation so that it follows the prisoner.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remind reception staff to share and record risk information on prisoner passports, and audit passport recording and use.
Verbatim wording from the response “All staff working in reception have been reminded of the importance of sharing risk information and ensuring that it is recorded on the prisoner passport. The first night custodial manager conducts regular audits of the prisoner passports to ensure that relevant information is being recorded, and that the document is being seen and used by staff working in reception.” Source location 2019-0175-Response-by-HM-Prison-Probation-Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Open an ACCT and require multidisciplinary review before reducing observations, recording decisions in the ACCT document.
Verbatim wording from the response “In all cases in which constant supervision has been in place, an Assessment, Care in Custody and Teamwork (ACCT) is opened and any decision to reduce the level of observations will be taken at a multidisciplinary case review (including the Duty Governor, a nurse and a member of prison staff, as well as the prisoner) and recorded in the ACCT document. All duty governors have been briefed and will frequently be reminded that decisions about the use of constant supervision should be based on the level of risk and must not be affected by resource constraints.” Source location 2019-0175-Response-by-HM-Prison-Probation-Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue a national learning bulletin guiding prisons on setting observation levels for prisoners at risk.
Verbatim wording from the response “With regard to your second concern, setting the appropriate level of observations for a prisoner who has been identified as being at risk is a difficult decision, and we have recently issued a learning bulletin to all prisons providing guidance about the issues to consider when making it. At HMP Bullingdon, the Governor has reminded the escort contractors of the importance of alerting reception staff in all cases in which constant supervision has been in place prior to a prisoner’s arrival. In all such cases the process is that the duty governor is informed and all documentation is studied to establish definitively the level of observations to which the prisoner has been subject, in order to avoid confusion over different organisational terminology.” Source location 2019-0175-Response-by-HM-Prison-Probation-Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require duty governors to establish prior observation levels from documentation when constant supervision preceded arrival.
Verbatim wording from the response “With regard to your second concern, setting the appropriate level of observations for a prisoner who has been identified as being at risk is a difficult decision, and we have recently issued a learning bulletin to all prisons providing guidance about the issues to consider when making it. At HMP Bullingdon, the Governor has reminded the escort contractors of the importance of alerting reception staff in all cases in which constant supervision has been in place prior to a prisoner’s arrival. In all such cases the process is that the duty governor is informed and all documentation is studied to establish definitively the level of observations to which the prisoner has been subject, in order to avoid confusion over different organisational terminology.” Source location 2019-0175-Response-by-HM-Prison-Probation-Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Brief duty governors that observation decisions must be risk-based and unaffected by resource constraints, with continuing reminders.
Verbatim wording from the response “In all cases in which constant supervision has been in place, an Assessment, Care in Custody and Teamwork (ACCT) is opened and any decision to reduce the level of observations will be taken at a multidisciplinary case review (including the Duty Governor, a nurse and a member of prison staff, as well as the prisoner) and recorded in the ACCT document. All duty governors have been briefed and will frequently be reminded that decisions about the use of constant supervision should be based on the level of risk and must not be affected by resource constraints.” Source location 2019-0175-Response-by-HM-Prison-Probation-Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remind escort contractors to alert reception staff when constant supervision preceded a prisoner’s arrival.
Verbatim wording from the response “With regard to your second concern, setting the appropriate level of observations for a prisoner who has been identified as being at risk is a difficult decision, and we have recently issued a learning bulletin to all prisons providing guidance about the issues to consider when making it. At HMP Bullingdon, the Governor has reminded the escort contractors of the importance of alerting reception staff in all cases in which constant supervision has been in place prior to a prisoner’s arrival. In all such cases the process is that the duty governor is informed and all documentation is studied to establish definitively the level of observations to which the prisoner has been subject, in order to avoid confusion over different organisational terminology.” Source location 2019-0175-Response-by-HM-Prison-Probation-Service
Open published response
31 Jan 2019 Andrew Stephen Carr · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 4 Failure to prevent drugs and other items being passed through the prison plumbing system View source Failure to record information about prisoner substance misuse and drug-related intelligence View source Uncontrolled use of contraband mobile phones contributing to substance misuse problems View source Failure to review information about prisoners entering the prison 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
Andrew Stephen Carr · 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 Stephen Carr, a prisoner, was found unresponsive in his cell on 29 March 2018 and was pronounced dead at 22:53 after attempts to revive him were unsuccessful. The medical cause of death was recorded as the effects of a synthetic cannabinoid. Concerns included failures to identify and record information about his prior substance use, the known use of the prison plumbing system to pass drugs, and the role of contraband mobile phones in substance misuse.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent drugs and other items being passed through the prison plumbing system
Wider context from the report “2. It had been known for approximately 5 years that drugs and other items could be passed through the plumbing system of the prison . No action was taken before Andrew’s death and the inquest heard that no solution had been found to the problem . This raises an ongoing concern for the wellbeing of prisoners and the risk of future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to record information about prisoner substance misuse and drug-related intelligence
Wider context from the report “1. The inquest heard evidence that before his transfer to Birmingham prison on 19/02/18 Andrew had been involved in 4 incidents of taking psychoactive substances resulting in a code blue being called. In addition there was intelligence that he may be giving out drugs. This information was available and passed onto Birmingham Prison - however they were not aware of it and did not record the information . The inquest heard that there was no time to review information of prisoners coming into the prison. This is a major concern as key information may not be identified and this poses a risk to the individual and other 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 Uncontrolled use of contraband mobile phones contributing to substance misuse problems
Wider context from the report “3. Many problems within the prison related to substances misuse are contributed to by the use of contraband mobile phones . The inquest heard evidence that blocking the use of mobile phones in prison would be very useful in mitigating this risk .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to review information about prisoners entering the prison
Wider context from the report “1. The inquest heard evidence that before his transfer to Birmingham prison on 19/02/18 Andrew had been involved in 4 incidents of taking psychoactive substances resulting in a code blue being called. In addition there was intelligence that he may be giving out drugs. This information was available and passed onto Birmingham Prison - however they were not aware of it and did not record the information. The inquest heard that there was no time to review information of prisoners coming into the prison . This is a major concern as key information may not be identified and this poses a risk to the individual and other prisoners.
” Open source report
Concerns raised 8 Failure to maintain single, accurate NOMIS and SystmOne records View source Failure to identify missing historical records and pause later consultations View source Delays in obtaining hearing aids for deaf prisoners View source Danger posed by Spice use in prisons View source Failure to refer prisoners formally to the equalities officer View source Absence of an equalities and disabilities questionnaire on prisoner arrival View source NOMIS failing to support necessary human intervention View source Failure of discipline and healthcare staff to recognise prisoners’ deafness View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Tyrone GIVANS · 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
Tyrone Givans, who was homeless, profoundly deaf and had a history of alcohol and drug use, was remanded into custody at HMP Pentonville after being arrested for assault. The jury concluded that he hanged himself in his cell, although his intentions were unclear. Principal concerns included Spice use in prison, duplicated prison and healthcare records that prevented access to earlier assessments, and inadequate recognition and support of his deafness and disabilities.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain single, accurate NOMIS and SystmOne records
Wider context from the report “2. A past spelling error meant that there were two sets of NOMIS prison records for Mr Givans. This meant that there were then two sets of SystmOne healthcare records .
This meant that staff did not have access to records of the assessments conducted before 8 February 2018. However, later consultations were not paused to make enquiries about this. The nature of the IT error was discovered after Mr Givans’ death, but at the time, staff did not seem to recognise the significance of having no earlier records.
Evidence was given that NOMIS in its present form is unsatisfactory and does not lend itself to human intervention. The jury found that the IT system was unfit for purpose.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to identify missing historical records and pause later consultations
Wider context from the report “2. A past spelling error meant that there were two sets of NOMIS prison records for Mr Givans. This meant that there were then two sets of SystmOne healthcare records.
This meant that staff did not have access to records of the assessments conducted before 8 February 2018 . However, later consultations were not paused to make enquiries about this . The nature of the IT error was discovered after Mr Givans’ death, but at the time, staff did not seem to recognise the significance of having no earlier records .
Evidence was given that NOMIS in its present form is unsatisfactory and does not lend itself to human intervention. The jury found that the IT system was unfit for purpose.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Delays in obtaining hearing aids for deaf prisoners
Wider context from the report “3. Some members of discipline and healthcare staff did not appreciate that Mr Givans was deaf, although others did. He was not formally referred to the prison equalities officer and there was a general lack of awareness of the role of equalities officer.
There was a delay in seeking Mr Givans’ hearing aids and it took two weeks for one to be brought in by a family member . Whilst systems in HMP Pentonville have changed since Mr Givans’ death, such a situation might exist in prisons elsewhere.
There remains no equalities/disabilities questionnaire for completion on prisoners’ arrival to the prison. The first night form could be adapted, but this would be an exercise to be undertaken nationally.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Danger posed by Spice use in prisons
Wider context from the report “1. Mr Givans’ former cell mate gave evidence that he had seen Mr Givans smoking Spice in their cell on two or three occasions, saying that its use is common within the prison. The jury heard that Spice often makes the user scared and paranoid, and can provoke immediate, extreme and uncharacteristic behaviour.
Drugs are of course a problem in all prisons and dealing with them a great challenge, but Spice poses a particular danger in all sorts of ways, both in Pentonville and across the prison estate.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to refer prisoners formally to the equalities officer
Wider context from the report “3. Some members of discipline and healthcare staff did not appreciate that Mr Givans was deaf, although others did. He was not formally referred to the prison equalities officer and there was a general lack of awareness of the role of equalities officer .
There was a delay in seeking Mr Givans’ hearing aids and it took two weeks for one to be brought in by a family member. Whilst systems in HMP Pentonville have changed since Mr Givans’ death, such a situation might exist in prisons elsewhere.
There remains no equalities/disabilities questionnaire for completion on prisoners’ arrival to the prison. The first night form could be adapted, but this would be an exercise to be undertaken nationally.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 an equalities and disabilities questionnaire on prisoner arrival
Wider context from the report “3. Some members of discipline and healthcare staff did not appreciate that Mr Givans was deaf, although others did. He was not formally referred to the prison equalities officer and there was a general lack of awareness of the role of equalities officer.
There was a delay in seeking Mr Givans’ hearing aids and it took two weeks for one to be brought in by a family member. Whilst systems in HMP Pentonville have changed since Mr Givans’ death, such a situation might exist in prisons elsewhere.
There remains no equalities/disabilities questionnaire for completion on prisoners’ arrival to the prison . The first night form could be adapted, but this would be an exercise to be undertaken nationally.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation NOMIS failing to support necessary human intervention
Wider context from the report “2. A past spelling error meant that there were two sets of NOMIS prison records for Mr Givans. This meant that there were then two sets of SystmOne healthcare records.
This meant that staff did not have access to records of the assessments conducted before 8 February 2018. However, later consultations were not paused to make enquiries about this. The nature of the IT error was discovered after Mr Givans’ death, but at the time, staff did not seem to recognise the significance of having no earlier records.
Evidence was given that NOMIS in its present form is unsatisfactory and does not lend itself to human intervention . The jury found that the IT system was unfit for purpose.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 discipline and healthcare staff to recognise prisoners’ deafness
Wider context from the report “3. Some members of discipline and healthcare staff did not appreciate that Mr Givans was deaf , although others did. He was not formally referred to the prison equalities officer and there was a general lack of awareness of the role of equalities officer.
There was a delay in seeking Mr Givans’ hearing aids and it took two weeks for one to be brought in by a family member. Whilst systems in HMP Pentonville have changed since Mr Givans’ death, such a situation might exist in prisons elsewhere.
There remains no equalities/disabilities questionnaire for completion on prisoners’ arrival to the prison. The first night form could be adapted, but this would be an exercise to be undertaken nationally.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a digital resource tool to collect personalised prisoner information and help staff identify appropriate adjustments.
Verbatim wording from the response “In addition to the above, a resource tool is being developed that will digitally collect more personalised information from prisoners, allowing staff to better understand their needs and identify adjustments that could be implemented to improve their quality of life and reduce unequal outcomes. This is currently in early development but we are looking to finalise proposals this month and to begin implementation in June/July 2019.” Source location 2019-0028-Response-by-HM-Prison-and-Probation-Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Bring operational, policy and partner colleagues together through the joint MOJ-HMPPS Drugs Taskforce to address drugs, including psychoactive substances, in prisons.
Verbatim wording from the response “In response to your concern about the dangers posed by the use of Spice, the joint Ministry of Justice (MOJ) and HMPPS Drugs Taskforce has brought together operational and policy colleagues and key partners to help tackle the problem of drugs, including psychoactive substances like Spice, in our prisons. As part of this, we have been working closely with those in law enforcement, health, and other government departments to develop a national Prison Drugs Strategy which was published in April this year. It provides strategic direction on how to reduce the use of drugs in prisons by restricting supply, reducing demand and building recovery. Alongside this, a Drugs Guidance Document provides examples of best practice for consideration by all those working within and in partnership with HMPPS to reduce the misuse of drugs in our prisons.” Source location 2019-0028-Response-by-HM-Prison-and-Probation-Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Run a monthly report to identify and merge duplicate prisoner records created by differing name spellings.
Verbatim wording from the response “You have raised the issue that when the name of a prisoner who has previously been in custody is spelt differently, a new record, which will not contain all the information about the prisoner, is created. At HMP Pentonville a monthly report is now run to identify any such cases and merge the records. Because NOMIS and SystmOne are separate IT platforms, designed and operated by separate government departments, the level of connectivity is limited. However, there are good local working practices now in place which encourage communication between prison and health teams. I understand that Care UK are also writing to you about this.” Source location 2019-0028-Response-by-HM-Prison-and-Probation-Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish the national Prison Drugs Strategy to direct action on restricting drug supply, reducing demand and building recovery in prisons.
Verbatim wording from the response “In response to your concern about the dangers posed by the use of Spice, the joint Ministry of Justice (MOJ) and HMPPS Drugs Taskforce has brought together operational and policy colleagues and key partners to help tackle the problem of drugs, including psychoactive substances like Spice, in our prisons. As part of this, we have been working closely with those in law enforcement, health, and other government departments to develop a national Prison Drugs Strategy which was published in April this year. It provides strategic direction on how to reduce the use of drugs in prisons by restricting supply, reducing demand and building recovery. Alongside this, a Drugs Guidance Document provides examples of best practice for consideration by all those working within and in partnership with HMPPS to reduce the misuse of drugs in our prisons.” Source location 2019-0028-Response-by-HM-Prison-and-Probation-Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide a Drugs Guidance Document containing best-practice examples for reducing drug misuse across HMPPS prisons and partner organisations.
Verbatim wording from the response “In response to your concern about the dangers posed by the use of Spice, the joint Ministry of Justice (MOJ) and HMPPS Drugs Taskforce has brought together operational and policy colleagues and key partners to help tackle the problem of drugs, including psychoactive substances like Spice, in our prisons. As part of this, we have been working closely with those in law enforcement, health, and other government departments to develop a national Prison Drugs Strategy which was published in April this year. It provides strategic direction on how to reduce the use of drugs in prisons by restricting supply, reducing demand and building recovery. Alongside this, a Drugs Guidance Document provides examples of best practice for consideration by all those working within and in partnership with HMPPS to reduce the misuse of drugs in our prisons.” Source location 2019-0028-Response-by-HM-Prison-and-Probation-Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish frontline staff guidance on disability and reasonable adjustments.
Verbatim wording from the response “In June this year, HMPPS will publish a Policy Framework document which will replace the existing Ensuring Equality Prison Service Instruction. It will include guidance on the implementation of reasonable adjustments, and will be complemented by the publication this summer of guidance for frontline staff on disability and reasonable adjustments.” Source location 2019-0028-Response-by-HM-Prison-and-Probation-Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Refresh the disability categorisation system with MOJ colleagues so NOMIS records are more efficient and descriptive than the existing yes-or-no method.
Verbatim wording from the response “In terms of the recording of information about disability, we are working with colleagues in the MOJ to refresh the categorisation system for disabilities so that the recording of such information on NOMIS is carried out more efficiently and is more descriptive, moving away from the ‘Yes/No’ method of recording. This will provide staff with more valuable and usable information about the needs of prisoners in their care and across the estate. The categorisation of disabilities will be based upon the categorisation of impairment used by the Office for National Statistics and Government Statistical Service.” Source location 2019-0028-Response-by-HM-Prison-and-Probation-Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise and republish HMP Pentonville’s local drug strategy.
Verbatim wording from the response “At a local level, in recognition of the dangers posed by the use of psychoactive substances, HMP Pentonville is revising and republishing its drug strategy and a Drug Strategy Committee has been reinstated as part of the local Safety Programme. The prison’s strategy takes an approach whereby access to psychoactive substances and other illegal substances is, as far as possible, limited, while meaningful support, in the form of education and psycho-social interventions, is provided to those who have used drugs or may be tempted to use them.” Source location 2019-0028-Response-by-HM-Prison-and-Probation-Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reinstate HMP Pentonville’s Drug Strategy Committee within the local Safety Programme.
Verbatim wording from the response “At a local level, in recognition of the dangers posed by the use of psychoactive substances, HMP Pentonville is revising and republishing its drug strategy and a Drug Strategy Committee has been reinstated as part of the local Safety Programme. The prison’s strategy takes an approach whereby access to psychoactive substances and other illegal substances is, as far as possible, limited, while meaningful support, in the form of education and psycho-social interventions, is provided to those who have used drugs or may be tempted to use them.” Source location 2019-0028-Response-by-HM-Prison-and-Probation-Service
Open published response
11 Jan 2019 Ricardo Wayne Holgate · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 4 Lack of CCTV coverage on all prison wings View source Failure to adequately manage illicit substance misuse in the prison View source Unavailability of airport-style scanners at prisoner reception and the visitor area View source Failure to prevent the use and supply of illicit substances in the prison 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
Ricardo Wayne Holgate · 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
Ricardo Wayne Holgate was found dead in his cell at Birmingham Prison on the morning of 26 March 2018. The post-mortem recorded coronary artery thrombosis and atherosclerosis, with the combined effects of synthetic cannabinoid and codeine. The inquest identified significant concerns about the supply and use of illicit substances, staffing levels, staff training and experience, and inconsistent management and reporting of prisoners affected by such substances.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Lack of CCTV coverage on all prison wings
Wider context from the report “1. The new Governing Governor confirmed that further steps are necessary to improve the management of illicit substance misuse. He confirmed the prison requires CCTV on all wings and airport style scanners – one in reception for prisoners and one in the visitor area.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to adequately manage illicit substance misuse in the prison
Wider context from the report “1. The new Governing Governor confirmed that further steps are necessary to improve the management of illicit substance misuse . He confirmed the prison requires CCTV on all wings and airport style scanners – one in reception for prisoners and one in the visitor area.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 airport-style scanners at prisoner reception and the visitor area
Wider context from the report “1. The new Governing Governor confirmed that further steps are necessary to improve the management of illicit substance misuse. He confirmed the prison requires CCTV on all wings and airport style scanners – one in reception for prisoners and one in the visitor area .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent the use and supply of illicit substances in the prison
Wider context from the report “2. Much progress has been made as a result of the appointment of the Governing Governor Paul Newton. His appointment was for 6 months. He advised at the inquest that there is much more work to do and extension of his appointment would allow further work to be undertaken to reduce the use and supply of illicit substances in the prison and to keep inmates safe.
” Open source report
4 Jan 2019 Mr Nicky Raymond Reilly · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 12 Lack of staff training and guidance for supporting prisoners with Asperger’s View source Delays in completing extremism risk assessment reports View source Failure to record and make psychology records accessible to psychologists View source Failure to continue the Care Program Approach after transfer to the Prison Service View source Failure to provide shared access to mental-health and psychology records View source Lack of psychiatric input into care plans View source Failure to escalate medication refusals appropriately View source Failure to provide further psychological input while awaiting transfer View source Lack of a single clear policy for managing medication refusals across weekdays and weekends View source Failure to provide an allocated SIU-based psychologist and continuing psychological input View source Failure to ensure multidisciplinary attendance and formal reports for care-plan meetings View source Inadequate documentary record keeping of care-plan meetings 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
Mr Nicky Raymond Reilly · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mr Nicky Raymond Reilly, also known as Mr Mohamed Saeed-Alim, was an inmate at HMP Manchester after spending six years at Broadmoor High Security Hospital. He was found hanging by a ligature in his cell on 19 October 2016 and was pronounced deceased at 14.43. The report raised concerns about the lack of continuation of the Care Program Approach, incomplete multidisciplinary records and coordination, limited psychological input and record keeping, insufficient staff training, separation of mental health and psychology records, and medication-refusal processes.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Lack of staff training and guidance for supporting prisoners with Asperger’s
Wider context from the report “The Court heard evidence as to the increase of prisoners within the Prison Service who potentially have a personality disorder or a degree of Aspergers and the limited services and places available. Of significance was the lack of training or guidance to staff on how to interact or accommodate someone with high functioning Aspergers such as NR. Please note the Court recognises the care provided by the SIU staff and the attempts some staff went to interact with NR, however there was no specific training or assistance given to them .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Delays in completing extremism risk assessment reports
Wider context from the report “The Extremism Risk assessment work had been concluded by ████████ in May 2016. Despite this, her report had not been completed at the time of NR’s death in October 2016 and she did not anticipate being in a position to complete the report until the New Year, some 8 months later. Whilst there is no evidence that in NR’s case this held up his referral to the Westgate Unit, given that a significant reason for his placement on the SIU prior to placement at Westgate, was to undertake this piece of work, a significant time had elapsed . In the meantime whilst waiting transfer, the Court heard no further Psychological input would be started with NR.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 and make psychology records accessible to psychologists
Wider context from the report “The Court received a copy of the psychology records kept by ████████ which the Court heard were the only Psychology records available. It was evident to the Court that there was little to no recording of information within the Psychology department . NR’s psychology medical records were at best, woeful. Moreover, as they were not kept in the Psychology department they were not available access to any other Psychologists .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 continue the Care Program Approach after transfer to the Prison Service
Wider context from the report “Whilst NR had been an in-patient at Broadmoor he had been subject to the Care Program Approach (CPA). There was no explanation as to why this was not continued when he was transferred back into the Prison Service. The lack of continuation of the CPA and the missed opportunities this presented, particularly in respect of earlier input from Psychiatry, for someone with such complex needs is of concern to the Court. Care plans relating to NR, as discussed below, should have had the benefit of Psychiatric input.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 shared access to mental-health and psychology records
Wider context from the report “The Court heard how the Mental Health team providing mental health services within HMP Manchester have a completely separate record keeping system (system 1) to the Psychology Team . Whilst acknowledging the Psychologists are employed by HMP Prison Service. However not all the psychologists were forensic psychologists as the Court heard ████████ was a clinical psychologist. There will inevitably be prisoners who require clinical psychological input for a range of diagnosis. Within a community setting such psychological services would be provided by the Mental Health Trust. Hence Psychologists would have access to the patients mental health records within the same Trust, where the same existed.
Where a prisoner is receiving both Mental Health input and Psychological input within a prison, there should be access to the appropriate medical records in order for each service to have a clear understanding of the patients clinical presentations and need. Having access to the totality of the information should then assist in appropriately assessing a patients risk to self and others.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 psychiatric input into care plans
Wider context from the report “Whilst NR had been an in-patient at Broadmoor he had been subject to the Care Program Approach (CPA). There was no explanation as to why this was not continued when he was transferred back into the Prison Service. The lack of continuation of the CPA and the missed opportunities this presented, particularly in respect of earlier input from Psychiatry, for someone with such complex needs is of concern to the Court. Care plans relating to NR, as discussed below, should have had the benefit of Psychiatric input.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate medication refusals appropriately
Wider context from the report “The Court heard evidence as to the lack of action taken by staff following NR's refusal of medication . The Court heard the process which should happen but this is not clearly documented in one policy which covers the situation for both weekdays and also weekends. There remains a risk particularly at a weekend that an appropriate escalation process would not be actioned by staff .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to provide further psychological input while awaiting transfer
Wider context from the report “The Extremism Risk assessment work had been concluded by ████████ in May 2016. Despite this, her report had not been completed at the time of NR’s death in October 2016 and she did not anticipate being in a position to complete the report until the New Year, some 8 months later. Whilst there is no evidence that in NR’s case this held up his referral to the Westgate Unit, given that a significant reason for his placement on the SIU prior to placement at Westgate, was to undertake this piece of work, a significant time had elapsed. In the meantime whilst waiting transfer, the Court heard no further Psychological input would be started with NR .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 single clear policy for managing medication refusals across weekdays and weekends
Wider context from the report “The Court heard evidence as to the lack of action taken by staff following NR's refusal of medication. The Court heard the process which should happen but this is not clearly documented in one policy which covers the situation for both weekdays and also weekends . There remains a risk particularly at a weekend that an appropriate escalation process would not be actioned by staff.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to provide an allocated SIU-based psychologist and continuing psychological input
Wider context from the report “NR had been allocated a Psychologist ████████ to undertake the specialist extremism work. However this meant he did not have an allocated psychologist who was based within the SIU .
The evidence to the Court from several witnesses including the Psychologists and SIU staff showed there was confusion as to whom was NR’s allocated Psychologist . The reality was from May 2016, NR received no psychological input and did not have an allocated Psychologist in any meaningful form .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 multidisciplinary attendance and formal reports for care-plan meetings
Wider context from the report “The Court heard evidence in respect of the quarterly meetings held by the CMG in respect of managing NRs care plan. The quality of documentary record keeping in respect of these meetings was limited. The absence of important multi-disciplinary attendees and lack of requirement of formal reports meant there was no-one who could provide full, accurate, informed information regarding NR, upon which decisions regarding his care could be made.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Inadequate documentary record keeping of care-plan meetings
Wider context from the report “The Court heard evidence in respect of the quarterly meetings held by the CMG in respect of managing NRs care plan. The quality of documentary record keeping in respect of these meetings was limited. The absence of important multi-disciplinary attendees and lack of requirement of formal reports meant there was no-one who could provide full, accurate, informed information regarding NR, upon which decisions regarding his care could be made.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver awareness events to improve staff confidence supporting prisoners with learning disabilities and other identified needs.
Verbatim wording from the response “A number of establishments have delivered awareness events aimed at improving staff confidence in dealing with prisoners with these needs, and nationally a toolkit has been developed to help staff better meet the needs of those in our care with Learning Disabilities and Challenges (LDC). The toolkit is designed for prisons and for probation service operational leaders at prisons, helping them to look at how their support, services and surroundings can better meet those needs and provide a more equal and fair service for those with LDC needs. It includes resources and practical tips, such as how to display information and make environments more engaging and inclusive.” Source location 2019-0014-Response-by-HM-Prison-and-Probation-Service
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement and embed the national Challenge Support Intervention Plan with multidisciplinary engagement, information-sharing, and effective record-keeping requirements.
Verbatim wording from the response “Whilst recognising the significance of the introduction of the new national case management model, Challenge Support Intervention Plan (CSIP), which replaced the MCBS policy on 1 February this year and is currently being implemented and embedded across the prison estate, you have expressed concern that some of the issues covered during the inquest may still be relevant. You have specifically referred to poor record keeping, the lack of multi-disciplinary attendees and the lack of requirement for formal reports.” Source location 2019-0014-Response-by-HM-Prison-and-Probation-Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and provide a learning-disability support toolkit with guidance and practical resources for prison and probation operational leaders.
Verbatim wording from the response “A number of establishments have delivered awareness events aimed at improving staff confidence in dealing with prisoners with these needs, and nationally a toolkit has been developed to help staff better meet the needs of those in our care with Learning Disabilities and Challenges (LDC). The toolkit is designed for prisons and for probation service operational leaders at prisons, helping them to look at how their support, services and surroundings can better meet those needs and provide a more equal and fair service for those with LDC needs. It includes resources and practical tips, such as how to display information and make environments more engaging and inclusive.” Source location 2019-0014-Response-by-HM-Prison-and-Probation-Service
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate weekly multidisciplinary meetings at HMP Manchester to manage complex and challenging prisoners and maintain decision-making records.
Verbatim wording from the response “HMP Manchester has been holding a weekly multi-disciplinary meeting to manage complex and challenging prisoners since April 2018, and CSIP was introduced in June 2018. The purpose of the weekly meeting is assist the Residential function by providing multi-disciplinary case management for prisoners who require additional resources over and above their CSIP or ACCT Intervention, Support or Care plans. Departments who do not attend are expected to provide written submissions to the meeting. The meetings are chaired by a Senior Manager from the Residential and Safety function, and minutes are kept to ensure an ongoing record of decision-making is maintained.” Source location 2019-0014-Response-by-HM-Prison-and-Probation-Service
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Medical confidentiality requirements prevent combining mental health and psychology records, so information sharing must use existing multidisciplinary forums.
Verbatim wording from the response “You have referred to mental health and psychology services record-keeping operating separately, with clinical records being held on SystmOne to which psychologists do not have access. While I recognise that this separation does carry the risk that information is not effectively shared, I must respect the medical in-confidence issues that make this necessary, and I expect all staff working in prisons to use the many forums available to them to work in a multi-disciplinary, collaborative way to ensure that decisions about prisoners are made with all available information.” Source location 2019-0014-Response-by-HM-Prison-and-Probation-Service
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Specialist Intervention Unit’s high staffing and staff support were considered sufficient for readjustment, without requiring formal psychological interventions.
Verbatim wording from the response “Your next concern is that Nicky did not have an allocated psychologist in the SIU and that no interventions were carried out following his completion of the Extremism Risk Assessment. While I recognise both points, I should clarify that Nicky’s allocation to the SIU was based on a range of factors, not solely so that formal interventions could be delivered. It is not uncommon for some complex individuals to be encouraged to focus on their involvement in the regime rather than on specific interventions at certain times. Nicky’s difficulty in coping within the custodial environment and the potential for this to present a high risk both to himself and to others meant that the SIU, as a small unit with a high staffing level, was considered the best environment for him to readjust to the prison setting and be offered sufficient support and care from staff.” Source location 2019-0014-Response-by-HM-Prison-and-Probation-Service
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Healthcare providers or prison mental health services determine whether an individual requires continuation of the Care Programme Approach.
Verbatim wording from the response “Your first concern is that, when Nicky was returned to the prison estate from Broadmoor, the Care Programme Approach (CPA) was not continued. As the CPA is a clinically-led programme to support those with mental health needs, the healthcare provider, or mental health services at a prison, is responsible for determining whether a CPA is required for an individual.” Source location 2019-0014-Response-by-HM-Prison-and-Probation-Service
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations