Concerns raised 1 Lack of clarity in PSI64/2011 guidance on first case review of an ACCT assessment View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
John Mayhew · 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 Mayhew died at HMP Durham on 15 January 2017 from self-inflicted hanging. He had a recent history of suicide attempts and made comments concerning potential self-harm or suicide after returning to custody, but the ACCT was closed at the initial case review without a care plan. The report raised concerns about the lack of involvement of the person who initiated the ACCT and the ambiguity of the relevant PSI 64/2011 attendance requirements.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity in PSI64/2011 guidance on first case review of an ACCT assessment
Wider context from the report “(1) Clarification is needed as to how to construe the part of PSI64/2011 dealing with first case review of an ACCT assessment, in particular the proviso in the words “whenever possible” as to which type of potential attendee it might apply.
(2) Consideration should be given to re-drafting this part of the PSI.
(3) Consideration might thereafter, be given, as to providing guidance on how this part of the PSI, if modified, should be applied in practice by all staff in all prisons.
” Open source report
Concerns raised 1 Lack of cardiopulmonary resuscitation training for some prison staff View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Nicola Jayne Lawrence · 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
Nicola Jayne Lawrence was an inmate at HMP New Hall who was found unresponsive on 24 September 2016 and died despite efforts by prison, healthcare and ambulance staff. The report raised concerns that healthcare staff had not considered the anti-respiratory or depressant effects of her medication, and that some prison staff had not received cardiopulmonary resuscitation 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 cardiopulmonary resuscitation training for some prison staff
Wider context from the report “(1) Some Prison staff had not received any cardiopulmonary resuscitation training. Either as part of initial training or any refresher training. Evidence was received that good quality CPR within the first few minutes of those who stopped breathing or heart stopped was critical.
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Risk-assessed staffing levels provide sufficient emergency first-aid response, and CPR training for all prison staff is not mandated.
Verbatim wording from the response “You may be aware that our approach is set out in PSI 29/2015 First Aid, which does not mandate first aid training for all staff, but requires Governors of public sector prisons to ensure that there are at all times sufficiently trained first aiders available. The appropriate number must be determined by conducting a first aid risk assessment, and first aiders must be trained to levels which are appropriate to the circumstances - to either First Aid at Work (FAW) level or Emergency First Aid at Work (EFAW) level.” Source location 2018-0318-Response-by-HM-Prison-Probation-Service
Open published response
19 Oct 2018 Robert Scott McLoughlin · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 2 Failure to conduct ACCT reviews during required periods View source Insufficient staffing levels for required prison operations 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
Robert Scott McLoughlin · 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 Scott McLoughlin, an inmate at HMP Leeds, was found suspended by a ligature on 20 February 2016 and died in hospital on 25 February 2016. The report raised concerns about very low staffing levels, including the absence of a Landing Officer, resulting in ACCT reviews not taking place for several hours.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct ACCT reviews during required periods
Wider context from the report “(1) The staffing levels at HMP Leeds were very low. On the evening of the 19th February 2016 when Mr McLoughlin self-harmed there was one Officer Support Grade on his wing. In addition there were only six Prison Officers on the night shift. On the morning of the 20th February 2016 the staffing levels were such that there was no Landing Officer on Mr McLoughlin’s landing. As a result ACCT reviews did not take place between approximately 0730 hours and 1340 hours .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Insufficient staffing levels for required prison operations
Wider context from the report “(1) The staffing levels at HMP Leeds were very low . On the evening of the 19th February 2016 when Mr McLoughlin self-harmed there was one Officer Support Grade on his wing . In addition there were only six Prison Officers on the night shift . On the morning of the 20th February 2016 the staffing levels were such that there was no Landing Officer on Mr McLoughlin’s landing . As a result ACCT reviews did not take place between approximately 0730 hours and 1340 hours.
” Open source report
11 Oct 2018 Dean Louis BARRELL · Prevention of Future Deaths report East Sussex
View report summary
Concerns raised 2 Delay in communicating actual release dates to custodial establishments View source Failure to inform vulnerable prisoners of their actual release dates promptly View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Dean Louis BARRELL · 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
Dean Barrell was found hanging in his cell at HMP Lewes on 13 February 2017, and the jury concluded that he had died by suicide. He had not been informed that he was due for release on 17 February 2017 and believed he would remain in prison until 29 April 2017. The report identified a seven-day delay in communicating his actual release date as a principal concern, particularly given the vulnerability of prisoners and the potential impact on his death.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Delay in communicating actual release dates to custodial establishments
Wider context from the report “Dean Barrell clearly thought he was in HMP Lewes for the remainder of his sentence (some 3 months). This was incorrect, as he was due for release on 17 February 2017. Had Mr Barrell been informed sooner and in a timely fashion, he may well have not taken his own life.
It took the Prison and Probation Service 7 days to communicate the actual release date to HMP Lewes. HMP Lewes attempted then to communicate this within 3 hours of receipt, but Mr Barrell had by then taken his own life.
Fixed term recalls for breach of licence conditions are not complex. By their very nature, they can result in short sentences to be served. Vulnerable prisoners deserve to know what their actual release date is, as soon as possible. A seven day delay as in this case, is simply unacceptable. The communication of the actual release date to a prisoner should, in this technological age, take less than 7 days.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to inform vulnerable prisoners of their actual release dates promptly
Wider context from the report “Dean Barrell clearly thought he was in HMP Lewes for the remainder of his sentence (some 3 months). This was incorrect, as he was due for release on 17 February 2017. Had Mr Barrell been informed sooner and in a timely fashion, he may well have not taken his own life.
It took the Prison and Probation Service 7 days to communicate the actual release date to HMP Lewes. HMP Lewes attempted then to communicate this within 3 hours of receipt, but Mr Barrell had by then taken his own life.
Fixed term recalls for breach of licence conditions are not complex. By their very nature, they can result in short sentences to be served. Vulnerable prisoners deserve to know what their actual release date is, as soon as possible. A seven day delay as in this case, is simply unacceptable. The communication of the actual release date to a prisoner should, in this technological age, take less than 7 days.
” 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 Publish a new recall policy framework retaining the notification requirement and revising the timeframe to one working day.
Verbatim wording from the response “This Probation Instruction remains in force; however a new policy framework covering recall actions will be published by the end of 2018. This framework retains the above requirement but, for the sake of clarity, revises the timeframe to one working day.” Source location Dean-BARRELL-Response
Open published response
25 Jun 2018 Andrew Craig · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 3 Ongoing use of prescription and illicit drugs at HMP Guys Marsh View source Failure of medication-dispensing arrangements to prevent undetected transfer of prescription drugs View source Failure to monitor whether prisoners swallow dispensed medication View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Andrew Craig · 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 Craig, a serving prisoner at HMP Guys Marsh, was found collapsed and unresponsive in his cell on 16 September 2016. The inquest concluded that the medical cause of death was the toxic effects of buprenorphine and diazepam, with a conclusion of misadventure. The principal concerns were illicit drug use at the prison and weaknesses in the dispensing and monitoring of medication, which could facilitate the redistribution of prescription drugs.
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 Ongoing use of prescription and illicit drugs at HMP Guys Marsh
Wider context from the report “i. There is an ongoing problem with the use of drugs, both prescription and illicit drugs such as psychoactive substances, at HMP Guys Marsh and there have been a number of recent deaths either confirmed to be, or suspected to be, due to drug use.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure of medication-dispensing arrangements to prevent undetected transfer of prescription drugs
Wider context from the report “ii. Evidence was given by the Head of Healthcare, ████████ that there are 3 allocated times during the day when Prisoners collect medication. During these times, there are around 70 prisoners collecting their medication. The room can be quite chaotic and loud, and prisoners can be in close contact clambering over each other. She described the hatch as overloaded. This is an ideal scenario to pass medication to one another without detection.
iii. In addition, during the routine medication dispensing, there are no checks done to confirm that Prisoners have actually swallowed the medication. This can allow them to retain the medication for redistribution.
iv. At the last inspection by Her Majesty’s Inspectorate of Prisons these issues were raised and attempts have been made to improve the situation. There are now Prison Officers at the Healthcare department during dispensing times, but usually only one Officer stood in the room where the medication hatch is located and another outside the room. Despite these changes, Mrs Jameson advised that the arrangements at medication dispensing times continue to be an ongoing problem that facilitates the illicit supply of prescription drugs in the Prison . She advised that the process could be made safer and more secure. Similar concerns were also raised by one of the Prison GPs ████████
████████
v. Mrs Jameson also gave evidence that the Prison is overwhelmed with illicit drug use, particularly psychoactive substances and that the Healthcare team receive 3 emergency calls a week at HMP Guys Marsh to assist in resuscitating Prisoners from drug overdoses.
2. I have concerns with regard to the following:
i. There is an ongoing problem with the use of drugs, both prescription and illicit drugs such as psychoactive substances, at HMP Guys Marsh and there have been a number of recent deaths either confirmed to be, or suspected to be, due to drug use.
ii. Although the Prison are working to address this, further consideration needs to be given to restricting the supply of such drugs. I would request that to prevent a future death at HMP Guys Marsh, there is a review of the policies and procedures by both the Prison Staff and the Healthcare Staff regarding the dispensing and monitoring of the medication administered at the medication hatch to ensure compliance and reduce distribution to 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 Failure to monitor whether prisoners swallow dispensed medication
Wider context from the report “ii. Evidence was given by the Head of Healthcare, ████████ that there are 3 allocated times during the day when Prisoners collect medication. During these times, there are around 70 prisoners collecting their medication. The room can be quite chaotic and loud, and prisoners can be in close contact clambering over each other. She described the hatch as overloaded. This is an ideal scenario to pass medication to one another without detection.
iii. In addition, during the routine medication dispensing, there are no checks done to confirm that Prisoners have actually swallowed the medication. This can allow them to retain the medication for redistribution.
iv. At the last inspection by Her Majesty’s Inspectorate of Prisons these issues were raised and attempts have been made to improve the situation. There are now Prison Officers at the Healthcare department during dispensing times, but usually only one Officer stood in the room where the medication hatch is located and another outside the room. Despite these changes, Mrs Jameson advised that the arrangements at medication dispensing times continue to be an ongoing problem that facilitates the illicit supply of prescription drugs in the Prison. She advised that the process could be made safer and more secure. Similar concerns were also raised by one of the Prison GPs ████████
████████
v. Mrs Jameson also gave evidence that the Prison is overwhelmed with illicit drug use, particularly psychoactive substances and that the Healthcare team receive 3 emergency calls a week at HMP Guys Marsh to assist in resuscitating Prisoners from drug overdoses.
2. I have concerns with regard to the following:
i. There is an ongoing problem with the use of drugs, both prescription and illicit drugs such as psychoactive substances, at HMP Guys Marsh and there have been a number of recent deaths either confirmed to be, or suspected to be, due to drug use.
ii. Although the Prison are working to address this, further consideration needs to be given to restricting the supply of such drugs. I would request that to prevent a future death at HMP Guys Marsh, there is a review of the policies and procedures by both the Prison Staff and the Healthcare Staff regarding the dispensing and monitoring of the medication administered at the medication hatch to ensure compliance and reduce distribution to others.
” 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 Hold multi-disciplinary weekly meetings to review the Spice action plan and share security intelligence.
Verbatim wording from the response “Staff from different areas in the prison including security, safer custody and healthcare attend weekly meetings which are held to discuss and review the action plan. The meetings provide an opportunity to discuss a wide range of relevant issues such as security intelligence and the dissemination of information about spice use.” Source location 2018-0194-Response-by-HM-Prison-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 Mark the dispensary floor, maintain CCTV coverage and provide wing staff with medication-attendance lists.
Verbatim wording from the response “The floor in front of the dispensary has been clearly marked so that prisoners know where to stand both for security purposes and to ensure that their own and other people’s privacy is respected. CCTV is in place in the dispensary area and wing staff are provided with lists of those who should be attending healthcare for medication.” Source location 2018-0194-Response-by-HM-Prison-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 Reduce drug availability through search dogs, mandatory drug testing, patrols and CCTV monitoring.
Verbatim wording from the response “A new local substance misuse policy has been developed in line with the Government Drug Strategy. The policy emphasises the importance of information sharing to tackle the problems associated with drugs in custody and prioritises reducing the availability of drugs in the prison through the use of search dogs and mandatory drug testing. The prison also tries to monitor any distribution of drugs around the prison through patrols and the use of CCTV.” Source location 2018-0194-Response-by-HM-Prison-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 Assign one person to manage medication queues, bullying prevention, concealed medication and related security information sharing.
Verbatim wording from the response “In future, managing the conduct of those queuing for medication, ensuring that there is no bullying and that no medication is concealed, will be the responsibility of one person, rather than a different officer every day. This will both provide consistency and improve security and information sharing between prison and healthcare.” Source location 2018-0194-Response-by-HM-Prison-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 Fit individual secure medication boxes in every cell for prisoners’ in-possession medication.
Verbatim wording from the response “Finally, HMP Guys Marsh has implemented a practice of medication management by which certain drugs will not be in the possession of prisoners but will be dispensed by healthcare. This is to prevent the drugs being diverted from one prisoner to another. Individual secure medication boxes have been ordered and will be fitted in each cell by the end of the year to allow each prisoner to safely store their in-possession medication. It is hoped that this will help to reduce the opportunity to take and misuse prescription drugs from others.” Source location 2018-0194-Response-by-HM-Prison-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 Use the Persistent Psychoactive Substances Intervention Plan for multi-disciplinary monitoring, information sharing and early intervention.
Verbatim wording from the response “The prison has also devised the Persistent Psychoactive Substances Intervention Plan (PPSIP) which works in a similar way to the ACCT documents. This plan is used as a monitoring and reviewing tool for prisoners who persistently abuse PS. Effective information sharing is key and the care of men on a PPSIP document is through a multi-disciplinary approach, using the skills of different staff as appropriate. The initiative allows early intervention and preventative work to promote prisoners’ wellbeing. It also helps them to take responsibility for themselves and to make informed, safer choices whilst in custody and out in the community.” Source location 2018-0194-Response-by-HM-Prison-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 Have prison staff support healthcare staff when prisoners may not have swallowed medication or are otherwise non-compliant.
Verbatim wording from the response “Having seen the response from Care UK I understand that healthcare staff will not be checking each person’s mouth to ensure that they have swallowed their medication. However, prison staff will be present to deal with any issues and will support healthcare staff when they have reason to believe that a prisoner has not swallowed medication or is being otherwise non-compliant.” Source location 2018-0194-Response-by-HM-Prison-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 Manage specified medications through healthcare dispensing rather than prisoner possession.
Verbatim wording from the response “Finally, HMP Guys Marsh has implemented a practice of medication management by which certain drugs will not be in the possession of prisoners but will be dispensed by healthcare. This is to prevent the drugs being diverted from one prisoner to another. Individual secure medication boxes have been ordered and will be fitted in each cell by the end of the year to allow each prisoner to safely store their in-possession medication. It is hoped that this will help to reduce the opportunity to take and misuse prescription drugs from others.” Source location 2018-0194-Response-by-HM-Prison-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 Implement a local substance-misuse policy aligned with the Government Drug Strategy.
Verbatim wording from the response “A new local substance misuse policy has been developed in line with the Government Drug Strategy. The policy emphasises the importance of information sharing to tackle the problems associated with drugs in custody and prioritises reducing the availability of drugs in the prison through the use of search dogs and mandatory drug testing. The prison also tries to monitor any distribution of drugs around the prison through patrols and the use of CCTV.” Source location 2018-0194-Response-by-HM-Prison-Probabtion-Service
Open published response
Concerns raised 1 Lack of suitable secure therapeutic environments for people with mental health problems in prison View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Emily Jayne Hartley · 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
Emily Jayne Hartley, a serving prisoner at HMP New Hall, was found suspended from a torn bed sheet in an out-of-bounds area during exercise on 23 April 2016; her death was confirmed at the scene. Concerns included serious deficiencies in the management, monitoring and recording of self-harm and suicide prevention procedures, weak information sharing and integrated planning, poor supervision, and the lack of a suitable secure therapeutic environment for people with significant mental health problems.
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 suitable secure therapeutic environments for people with mental health problems in prison
Wider context from the report “(1) It became apparent from the evidence of many Prison Officers and Healthcare Workers that Prison was not the appropriate environment for someone with Emily’s mental health problems . The emphasis should have been on treatment but within a secure environment which Prison, with the most well intentioned staff, cannot adequately provide .
(2) Coincidentally ten years ago I heard an Inquest into the death of Petra Blankbsy, also at New Hall Prison. At the conclusion of this inquest I made a recommendation pursuant to what was then Rule 43 of the Coroner’s Rules 1984. I attach a copy of my Rule 43 recommendations which I repeat in every detail in respect of the death of Emily Jayne Hartley. Furthermore I state that a Prison is not the appropriate place to accommodate Emily and that there should be facilities, particularly in the Prison’s female estate, to provide a therapeutic yet secure environment with the emphasis being on treatment .
I repeat ten years later that the Prison’s department and the Department of Health should conduct a collaborative exercise to achieve the provision of suitable, secure, therapeutic environments in order to treat those with mental health problems of the nature of those demonstrated by Petra Blanksby ten years ago and now Emily Jayne Hartley. I would refer you to a paper prepared by “Inquest” entitled Preventing the Deaths of Women in Prison and the Need for an Alternative Approach which was published in June 2013 and also a report by ████████ of a review of Women with Particular Vulnerabilities in the Criminal Justice System.
” Open source report
15 Feb 2018 Timothy John Shaw · Prevention of Future Deaths report Essex
View report summary
Concerns raised 7 Inadequate standard and accuracy of record keeping by disciplinary and healthcare staff View source Inadequate communication between healthcare and disciplinary staff about the purpose of Intelligence Reports View source Inadequate processes and systems for reducing access to illegal substances View source Lack of an appropriate audit system View source Lack of criteria and a system for Intelligence Reports View source Inadequate referral processes to psychosocial services View source Failure of healthcare staff to complete Intelligence Reports correctly View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Timothy John Shaw · 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
Timothy John Shaw, aged 34, was found collapsed in his prison cell on 28 February 2017 after apparent substance use and died in hospital on 2 March 2017. The report identified concerns about communication, intelligence reporting, access to illegal substances, referrals to psychosocial services, and record keeping.
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 standard and accuracy of record keeping by disciplinary and healthcare staff
Wider context from the report “The standard and accuracy of record keeping by both disciplinary and Healthcare staff needs to be improved.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Inadequate communication between healthcare and disciplinary staff about the purpose of Intelligence Reports
Wider context from the report “Healthcare staff seemed unclear as to how to fill in an Intelligence Report. There needs to be better communication between Healthcare staff and disciplinary staff as to the purpose of an Intelligence Report. Some criteria need to be developed and a system in place. An appropriate audit system needs to be in place.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Inadequate processes and systems for reducing access to illegal substances
Wider context from the report “The processes and systems for reducing access to illegal substances need to be improved and tightened up
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Lack of an appropriate audit system
Wider context from the report “Healthcare staff seemed unclear as to how to fill in an Intelligence Report. There needs to be better communication between Healthcare staff and disciplinary staff as to the purpose of an Intelligence Report. Some criteria need to be developed and a system in place. An appropriate audit system needs to be in place.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Lack of criteria and a system for Intelligence Reports
Wider context from the report “Healthcare staff seemed unclear as to how to fill in an Intelligence Report. There needs to be better communication between Healthcare staff and disciplinary staff as to the purpose of an Intelligence Report. Some criteria need to be developed and a system in place. An appropriate audit system needs to be in place.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Inadequate referral processes to psychosocial services
Wider context from the report “The processes for referrals by both prisoners and staff to psychosocial services needs to be tightened up and improved.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 healthcare staff to complete Intelligence Reports correctly
Wider context from the report “Healthcare staff seemed unclear as to how to fill in an Intelligence Report. There needs to be better communication between Healthcare staff and disciplinary staff as to the purpose of an Intelligence Report. Some criteria need to be developed and a system in place. An appropriate audit system needs to be in place.
” Open source report
20 Dec 2017 Craig David Royce · Prevention of Future Deaths report Essex
View report summary
Concerns raised 1 Lack of a reliable documentary system for communicating mental health referral information 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
Craig David Royce · 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
Craig Royce, who had a history of mental health problems and epilepsy, was found hanging in his prison cell on 24 December 2016. The report identified concerns that a referral to mental health services following an incident of self-harm was not made and that there was no robust documentary system for communicating such referrals. The inquest jury also considered that his risk of self-harm or suicide was not properly reviewed with appropriate precautions taken.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Lack of a reliable documentary system for communicating mental health referral information
Wider context from the report “There is no form/template to deal with the situation of a prisoner who needs to be referred to the mental health service. Reliance upon the transfer of this vital information to Healthcare by means of a telephone conversation could be unreliable. A robust, simple documentary system is required for the communication of such important information , namely that a prisoner needs to be referred to mental health services for an assessment to be carried out by mental health services. This would be distinct from the TAG system which caters for a brief assessment to be relayed across.
” Open source report
18 Dec 2017 MARK ANTHONY DOYLE · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 9 Lack of clear criteria and defined information for assessing fitness for transfer from F Wing View source Failure to identify and record prisoner-specific trigger factors on ACCT records View source Failure to consider relevant ACCT file material when determining observation frequency View source Lack of process for recording transfer decisions, reasons and decision-maker identity View source Failure to involve prison staff who know the prisoner in ACCT reviews View source Failure to share relevant healthcare information on prisoners’ ACCT records View source Lack of mandatory first aid training for existing prison officers View source Failure to read recent risk-relevant ACCT daily record entries during case reviews View source Poor understanding of when to contact a prisoner’s family during ACCT reviews View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
MARK ANTHONY DOYLE · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mark Anthony Doyle was found suspended by a ligature attached to his cell window bars on 21 March 2017 and died in hospital on 28 March 2017 from injuries sustained in the suspension. The inquest identified concerns including errors in recording a significant anniversary on his ACCT, his transfer from F Wing, and a delay in responding to his cell bell. Further concerns related to ACCT review and information-sharing practices, unclear criteria and recording for transfers from F Wing, and the lack of mandatory first-aid training for existing 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 Lack of clear criteria and defined information for assessing fitness for transfer from F Wing
Wider context from the report “(3) Decisions that prisoners are fit to be transferred from F Wing are made and conveyed to prison staff by the charge nurse on duty that morning annotating by hand a list of the prisoners on the Wing. There appears to be no clear criteria for assessing when a prisoner is fit for transfer; the information that should be considered in making this determination is left to the discretion of the decision maker ; and there is no process for recording the decision, the reasons for it or the identity of the decision maker in the prisoner’s records or otherwise.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to identify and record prisoner-specific trigger factors on ACCT records
Wider context from the report “(1) Although recent developments regarding multi-disciplinary involvement in ACCT case reviews and quality assurance ACCT checks are encouraging (as described to me by ████████, Head of Safer Custody), I remain concerned that the following failings were apparent in the ACCT case reviews concerning Mr Doyle conducted on 10 and 20 March 2017, but are not addressed / adequately addressed by the recent initiatives (including the new Weekly Quality Assurance Check):
• Insufficient appreciation of the importance of identifying and recording trigger factors for a particular prisoner on their ACCT inside front cover ;
• Officers undertaking case reviews without reading recent entries on the ACCT daily record relevant to risk;
• Officers determining the frequency of observation levels for an ACCT prisoner without considering relevant material in the ACCT file;
• The ACCT reviewer failing to appreciate the value of involving at least one member of the prison staff who knows the prisoner; and
• Circumstances in which a prisoner’s family could or should be contacted as part of the ACCT review process were poorly understood.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 consider relevant ACCT file material when determining observation frequency
Wider context from the report “(1) Although recent developments regarding multi-disciplinary involvement in ACCT case reviews and quality assurance ACCT checks are encouraging (as described to me by ████████, Head of Safer Custody), I remain concerned that the following failings were apparent in the ACCT case reviews concerning Mr Doyle conducted on 10 and 20 March 2017, but are not addressed / adequately addressed by the recent initiatives (including the new Weekly Quality Assurance Check):
• Insufficient appreciation of the importance of identifying and recording trigger factors for a particular prisoner on their ACCT inside front cover;
• Officers undertaking case reviews without reading recent entries on the ACCT daily record relevant to risk;
• Officers determining the frequency of observation levels for an ACCT prisoner without considering relevant material in the ACCT file ;
• The ACCT reviewer failing to appreciate the value of involving at least one member of the prison staff who knows the prisoner; and
• Circumstances in which a prisoner’s family could or should be contacted as part of the ACCT review process were poorly understood.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Lack of process for recording transfer decisions, reasons and decision-maker identity
Wider context from the report “(3) Decisions that prisoners are fit to be transferred from F Wing are made and conveyed to prison staff by the charge nurse on duty that morning annotating by hand a list of the prisoners on the Wing. There appears to be no clear criteria for assessing when a prisoner is fit for transfer; the information that should be considered in making this determination is left to the discretion of the decision maker; and there is no process for recording the decision, the reasons for it or the identity of the decision maker in the prisoner’s records or otherwise .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 involve prison staff who know the prisoner in ACCT reviews
Wider context from the report “(1) Although recent developments regarding multi-disciplinary involvement in ACCT case reviews and quality assurance ACCT checks are encouraging (as described to me by ████████, Head of Safer Custody), I remain concerned that the following failings were apparent in the ACCT case reviews concerning Mr Doyle conducted on 10 and 20 March 2017, but are not addressed / adequately addressed by the recent initiatives (including the new Weekly Quality Assurance Check):
• Insufficient appreciation of the importance of identifying and recording trigger factors for a particular prisoner on their ACCT inside front cover;
• Officers undertaking case reviews without reading recent entries on the ACCT daily record relevant to risk;
• Officers determining the frequency of observation levels for an ACCT prisoner without considering relevant material in the ACCT file;
• The ACCT reviewer failing to appreciate the value of involving at least one member of the prison staff who knows the prisoner ; and
• Circumstances in which a prisoner’s family could or should be contacted as part of the ACCT review process were poorly understood.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 healthcare information on prisoners’ ACCT records
Wider context from the report “(2) Although, ████████, Head of Healthcare, described how healthcare staff have received recent encouragement to make entries on a prisoner’s ACCT in relation to matters that could bear on risk, I am concerned that this does not go far enough to change past practice and ensure that relevant information is shared , in light of the prison staff’s lack of access to System One records and the infrequent occasions that Care UK staff made entries on Mr Doyle’s ACCT daily record .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Lack of mandatory first aid training for existing prison officers
Wider context from the report “(4) There is no mandatory first aid training for existing (as opposed to new) prison officers . I was informed that Orderly Officers and OSGs have / are being provided with first aid training, but I am concerned this remains a serious lacuna. I appreciate it is a nationally made resourcing decision and that it has been raised previously, but I raise it for further consideration; in light of the limited number of prison and nursing staff on duty overnight, there is a real prospect of medical emergencies arising where no trained first aider is available .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 read recent risk-relevant ACCT daily record entries during case reviews
Wider context from the report “(1) Although recent developments regarding multi-disciplinary involvement in ACCT case reviews and quality assurance ACCT checks are encouraging (as described to me by ████████, Head of Safer Custody), I remain concerned that the following failings were apparent in the ACCT case reviews concerning Mr Doyle conducted on 10 and 20 March 2017, but are not addressed / adequately addressed by the recent initiatives (including the new Weekly Quality Assurance Check):
• Insufficient appreciation of the importance of identifying and recording trigger factors for a particular prisoner on their ACCT inside front cover;
• Officers undertaking case reviews without reading recent entries on the ACCT daily record relevant to risk ;
• Officers determining the frequency of observation levels for an ACCT prisoner without considering relevant material in the ACCT file;
• The ACCT reviewer failing to appreciate the value of involving at least one member of the prison staff who knows the prisoner; and
• Circumstances in which a prisoner’s family could or should be contacted as part of the ACCT review process were poorly understood.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Poor understanding of when to contact a prisoner’s family during ACCT reviews
Wider context from the report “(1) Although recent developments regarding multi-disciplinary involvement in ACCT case reviews and quality assurance ACCT checks are encouraging (as described to me by ████████, Head of Safer Custody), I remain concerned that the following failings were apparent in the ACCT case reviews concerning Mr Doyle conducted on 10 and 20 March 2017, but are not addressed / adequately addressed by the recent initiatives (including the new Weekly Quality Assurance Check):
• Insufficient appreciation of the importance of identifying and recording trigger factors for a particular prisoner on their ACCT inside front cover;
• Officers undertaking case reviews without reading recent entries on the ACCT daily record relevant to risk;
• Officers determining the frequency of observation levels for an ACCT prisoner without considering relevant material in the ACCT file;
• The ACCT reviewer failing to appreciate the value of involving at least one member of the prison staff who knows the prisoner; and
• Circumstances in which a prisoner’s family could or should be contacted as part of the ACCT review process were poorly understood .
” Open source report
Concerns raised 4 Lack of formal training in reception duties View source Failure to inform staff of the manner of unnatural prisoner deaths View source Lack of written material informing reception officers of their duties View source Unavailability of breathing guards for senior officers during resuscitation 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
Christopher Talbot · 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
Christopher Talbot, a prisoner at Preston Prison, was found with a plastic bag over his head after being identified as vulnerable and at risk of suicide. Resuscitation initially restored breathing and cardiac output, but he later died in hospital. Concerns included inadequate reception training, the absence of a breathing guard during resuscitation, insufficient sharing of information about similar deaths, and failures to request immediate assistance and maintain constant observation.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Lack of formal training in reception duties
Wider context from the report “(1) The Supervising Officer on duty at Reception when Mr Talbot arrived had never received training in her duties but merely gained experience by shadowing another officer . It did not appear that any written material was provided so as to inform her of her duties, including the PSI “Early Days In Custody, Reception In, First Night In Custody And Induction To Custody” or a guidance document summarising the main provisions of the PSI. Lack of such written material and reliance solely on shadowing as a means of training might bring about a position where bad habits are proliferated or important considerations missed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to inform staff of the manner of unnatural prisoner deaths
Wider context from the report “(3) It is understood that following the death of a prisoner a notice to this effect is issued to the prisoners and staff but that staff are not informed of the manner of an unnatural death . Thus, it appeared that staff attending to give evidence at the inquest were unaware of another recent previous death involving a plastic bag , knowledge of which might have led to extra vigilance in the case of Mr Talbot, when as a vulnerable prisoner, he was observed holding a plastic bag.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 material informing reception officers of their duties
Wider context from the report “(1) The Supervising Officer on duty at Reception when Mr Talbot arrived had never received training in her duties but merely gained experience by shadowing another officer. It did not appear that any written material was provided so as to inform her of her duties , including the PSI “Early Days In Custody, Reception In, First Night In Custody And Induction To Custody” or a guidance document summarising the main provisions of the PSI. Lack of such written material and reliance solely on shadowing as a means of training might bring about a position where bad habits are proliferated or important considerations missed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Unavailability of breathing guards for senior officers during resuscitation
Wider context from the report “(2) A Senior Officer gave mouth to mouth resuscitation to Mr Talbot without the use of a guard. It is understood that although mandatory for more junior officers at HMP Preston, carrying a breathing guard at all times is discretionary for certain senior grades . Lack of such a guard might put an officer in personal danger when attempting to revive a prisoner or dissuade that officer from intervening , with potential adverse consequences for the prisoner.
” Open source report
19 Oct 2017 Sean Patrick Plumstead · Prevention of Future Deaths report Central Hampshire
View report summary
Concerns raised 13 Failure to provide ACCT training to all relevant prison staff View source Inadequate storage of staff interview recordings View source Inadequate storage of telephone recordings View source Emergency cell bell system lacking call prioritisation and activation-time identification View source Lack of an alternative means for prisoners to request emergency assistance View source Failure to retain important documents or electronic material with specific prisoner records View source Failure to maintain adequate suicide and self-harm awareness training coverage View source Failure to train all prisoner-facing Carillion staff in self-harm and suicide prevention View source Insufficiently resourced transcription of staff interviews View source Failure to maintain training records for Carillion prisoner-facing staff View source Unclear allocation of responsibility for training prisoner-facing contractor staff View source Inadequate control of emergency cell bell misuse View source Delays in responding to emergency cell bell activations View source See 10 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Sean Patrick Plumstead · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Sean Plumstead, a convicted prisoner at HM Prison Winchester, died on 18 September 2016 after being found hanging by a ligature in his cell and later having treatment withdrawn following severe brain injury. The report raised concerns about inadequate suicide and self-harm awareness training for prison and prisoner-facing staff, unclear responsibility for training Carillion staff, and delayed responses to emergency cell bells.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to provide ACCT training to all relevant prison staff
Wider context from the report “1. ACCT Training
I issued a Regulation 28 Report on 4 October 2016 in relation to a death of another prisoner at HMP Winchester ████████ concerning inter alia Assessment Care and Custody and Teamwork (ACCT) training plans and received a response from the Ministry of Justice dated 12 December 2016 in which it was stated that refresher training was taking place for 48 members of staff that month and at least monthly thereafter and that 12 new prison officers were expected to complete the Prison Officer Entry Level Training course that includes training on suicide and self-harm awareness (SASH) and ACCT process before starting work at Winchester by March 2017.
In an inquest starting on 13 March 2017 in relation to a death of another prisoner at HMP Winchester ████████ evidence was given by the prison governor that at August 2016 41% of staff had received ACCT training ; at the date the evidence was given 61% of staff had received ACCT training ; and that the aim was for 80% of staff to receive ACCT training by Autumn 2017. The Assistant Coroner issued a Regulation 28 Report on 11 April 2017 concerning inter alia ACCT training plans and received a response from the Ministry of Justice dated 21 June 2017 which stated that at the date of the letter 120 out of 162 prison officers at HMP Winchester (74%) had received ACCT training .
Evidence adduced in the inquest into the death of Mr Plumstead disclosed statistics for the provision of SASH training had been completed as follows:
• As at September 2016 77.29% of forward- facing prison service staff
• As at September 2016 64.27% of all prison service staff
• As at September 2017 72% of forward- facing prison service staff
• As at September 2017 57% of prison service staff were “in date” with such training.
The evidence was that the current aim is to achieve the 80% target by mid 2018.
It was apparent from the evidence that due to staff turnover, a lack of trainers qualified and available to provide such training and other priorities, targets for SASH training are failing to be met and if anything the ratio of prison staff with the appropriate skills is reducing rather than increasing. This means that the risk of prisoners at risk of self harm and suicide may not be recognised by staff who have had no such training with whom they come into contact.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 storage of staff interview recordings
Wider context from the report “(2) Winchester Prison has been unable to produce recordings of the interviews of staff and it has been stated that due to resourcing constraints written transcripts of some of the interviews were not prepared. It is uncertain whether the relevant assistant governor will be able to give live evidence of the results of her investigation and one of the officers involved is on long term absence. The systems in place for proper storage of such recordings appear to be inadequate and the administrative processes for transcription are insufficiently resourced.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 storage of telephone recordings
Wider context from the report “(1) Winchester Prison has been unable to produce the telephone recordings and the transcripts provided are in summary form only and so may omit potential evidence. The systems in place for proper storage of such material appear to be inadequate or non-existent.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Emergency cell bell system lacking call prioritisation and activation-time identification
Wider context from the report “3. Emergency Cell Bells
The emergency cell bell (ECB) in Mr Plumstead’s cell had been activated by his cellmate but the response to this took 10.5 minutes whereas the expected response time is 5 minutes. The evidence showed that there was and continues to be widespread misuse of ECB’s by prisoners particularly those on general wings, which leads to prison officers responding on occasions over an hour after the ECB has been activated. There are only limited sanctions available for enforcement of the proper use of the system by prisoners. The system allows no means of prioritising calls or identifying the time when the ECB has been pressed . Prisoners who have a genuine emergency have no alternative means of requesting assistance and therefore the risk is that there medical emergencies will not have a timely response and further deaths in such circumstances will occur. The current system is not fit for purpose and notices to prisoners are ineffective.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Lack of an alternative means for prisoners to request emergency assistance
Wider context from the report “3. Emergency Cell Bells
The emergency cell bell (ECB) in Mr Plumstead’s cell had been activated by his cellmate but the response to this took 10.5 minutes whereas the expected response time is 5 minutes. The evidence showed that there was and continues to be widespread misuse of ECB’s by prisoners particularly those on general wings, which leads to prison officers responding on occasions over an hour after the ECB has been activated. There are only limited sanctions available for enforcement of the proper use of the system by prisoners. The system allows no means of prioritising calls or identifying the time when the ECB has been pressed. Prisoners who have a genuine emergency have no alternative means of requesting assistance and therefore the risk is that there medical emergencies will not have a timely response and further deaths in such circumstances will occur. The current system is not fit for purpose and notices to prisoners are ineffective.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to retain important documents or electronic material with specific prisoner records
Wider context from the report “(3) This is not the first death in custody at Winchester Prison where potentially important documents or electronic material has been mislaid or not found because they have not been retained with specific prisoner records . There is therefore a risk that future deaths at the prison occur when such omissions are repeated.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 adequate suicide and self-harm awareness training coverage
Wider context from the report “1. ACCT Training
I issued a Regulation 28 Report on 4 October 2016 in relation to a death of another prisoner at HMP Winchester ████████ concerning inter alia Assessment Care and Custody and Teamwork (ACCT) training plans and received a response from the Ministry of Justice dated 12 December 2016 in which it was stated that refresher training was taking place for 48 members of staff that month and at least monthly thereafter and that 12 new prison officers were expected to complete the Prison Officer Entry Level Training course that includes training on suicide and self-harm awareness (SASH) and ACCT process before starting work at Winchester by March 2017.
In an inquest starting on 13 March 2017 in relation to a death of another prisoner at HMP Winchester ████████ evidence was given by the prison governor that at August 2016 41% of staff had received ACCT training; at the date the evidence was given 61% of staff had received ACCT training; and that the aim was for 80% of staff to receive ACCT training by Autumn 2017. The Assistant Coroner issued a Regulation 28 Report on 11 April 2017 concerning inter alia ACCT training plans and received a response from the Ministry of Justice dated 21 June 2017 which stated that at the date of the letter 120 out of 162 prison officers at HMP Winchester (74%) had received ACCT training.
Evidence adduced in the inquest into the death of Mr Plumstead disclosed statistics for the provision of SASH training had been completed as follows:
• As at September 2016 77.29% of forward- facing prison service staff
• As at September 2016 64.27% of all prison service staff
• As at September 2017 72% of forward- facing prison service staff
• As at September 2017 57% of prison service staff were “in date” with such training.
The evidence was that the current aim is to achieve the 80% target by mid 2018.
It was apparent from the evidence that due to staff turnover, a lack of trainers qualified and available to provide such training and other priorities, targets for SASH training are failing to be met and if anything the ratio of prison staff with the appropriate skills is reducing rather than increasing . This means that the risk of prisoners at risk of self harm and suicide may not be recognised by staff who have had no such training with whom they come into contact.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 train all prisoner-facing Carillion staff in self-harm and suicide prevention
Wider context from the report “2. Training of All Prisoner-facing Staff
The investigation into the death of Sean Plumstead, including evidence heard during the inquest, has highlighted matters of concern relating to Carillion’s past and present operations at HMP Winchester and possibly at other establishments nationally. The evidence showed that in the 18 months before Mr Plumstead’s death in September 2016, at least two Carillion staff were employed in prisoner-facing roles at the prison (in the Clothing Exchange Store) without any training in self-harm/suicide prevention (in apparent contradiction to the national policy - the Prison Service Instruction 64/2011 in its latest version). Further, one of those staff members was expected to make entries in an (ACCT) support document without having had relevant training. As of October 2017, one of those staff members has still to be trained in self-harm/suicide prevention .
It remains unclear whether the (Carillion) Works Manager and other Carillion supervisors (at a local and national level) are aware of the issue. The prison have since assumed the responsibility for the training of all staff in prisoner-facing roles but there is, as yet, no clarity on the obligations and assumptions which Ministry of Justice and Carillion were operating at the material time (2015-2016) nor indeed what arrangements will pertain in the future. Indeed, I have also heard evidence that the prison do not hold training records for Carillion staff. There is therefore some division of responsibility between the prison and Carillion and a risk that training of staff is missed because of the absence of such records.
I consider there is a risk arising from my investigation that there was and continues to be a gap in training which Carillion is either unaware of or unconcerned with - a gap that may continue here and elsewhere. I understand that Carillion has a contractual obligation to ensure that staff provided to the prison will be appropriately trained, but I cannot identify any requirement for self-harm/suicide management training, nor any commitment by Carillion to make staff available for such training by the prison as necessary. The apparent ambiguities in the arrangement could compromise the safety of prisoners that Carillion personnel are dealing with.
I am also concerned of a risk in other prisons, where Carillion staff are directly engaging with prisoners without adequate or appropriate training in suicide and self-harm management. I invited Carillion to be an Interested Party to the inquest, a request which they declined to take up. Nevertheless, following the evidence in the inquest, the prima facie concerns have hardened. I consider Carillion has the power to take action to remedy these shortcomings and that in collaboration with the Ministry of Justice both can address these concerns and clarify responsibilities.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Insufficiently resourced transcription of staff interviews
Wider context from the report “(2) Winchester Prison has been unable to produce recordings of the interviews of staff and it has been stated that due to resourcing constraints written transcripts of some of the interviews were not prepared . It is uncertain whether the relevant assistant governor will be able to give live evidence of the results of her investigation and one of the officers involved is on long term absence. The systems in place for proper storage of such recordings appear to be inadequate and the administrative processes for transcription are insufficiently resourced .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 training records for Carillion prisoner-facing staff
Wider context from the report “2. Training of All Prisoner-facing Staff
The investigation into the death of Sean Plumstead, including evidence heard during the inquest, has highlighted matters of concern relating to Carillion’s past and present operations at HMP Winchester and possibly at other establishments nationally. The evidence showed that in the 18 months before Mr Plumstead’s death in September 2016, at least two Carillion staff were employed in prisoner-facing roles at the prison (in the Clothing Exchange Store) without any training in self-harm/suicide prevention (in apparent contradiction to the national policy - the Prison Service Instruction 64/2011 in its latest version). Further, one of those staff members was expected to make entries in an (ACCT) support document without having had relevant training. As of October 2017, one of those staff members has still to be trained in self-harm/suicide prevention.
It remains unclear whether the (Carillion) Works Manager and other Carillion supervisors (at a local and national level) are aware of the issue. The prison have since assumed the responsibility for the training of all staff in prisoner-facing roles but there is, as yet, no clarity on the obligations and assumptions which Ministry of Justice and Carillion were operating at the material time (2015-2016) nor indeed what arrangements will pertain in the future. Indeed, I have also heard evidence that the prison do not hold training records for Carillion staff . There is therefore some division of responsibility between the prison and Carillion and a risk that training of staff is missed because of the absence of such records .
I consider there is a risk arising from my investigation that there was and continues to be a gap in training which Carillion is either unaware of or unconcerned with - a gap that may continue here and elsewhere. I understand that Carillion has a contractual obligation to ensure that staff provided to the prison will be appropriately trained, but I cannot identify any requirement for self-harm/suicide management training, nor any commitment by Carillion to make staff available for such training by the prison as necessary. The apparent ambiguities in the arrangement could compromise the safety of prisoners that Carillion personnel are dealing with.
I am also concerned of a risk in other prisons, where Carillion staff are directly engaging with prisoners without adequate or appropriate training in suicide and self-harm management. I invited Carillion to be an Interested Party to the inquest, a request which they declined to take up. Nevertheless, following the evidence in the inquest, the prima facie concerns have hardened. I consider Carillion has the power to take action to remedy these shortcomings and that in collaboration with the Ministry of Justice both can address these concerns and clarify responsibilities.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Unclear allocation of responsibility for training prisoner-facing contractor staff
Wider context from the report “2. Training of All Prisoner-facing Staff
The investigation into the death of Sean Plumstead, including evidence heard during the inquest, has highlighted matters of concern relating to Carillion’s past and present operations at HMP Winchester and possibly at other establishments nationally. The evidence showed that in the 18 months before Mr Plumstead’s death in September 2016, at least two Carillion staff were employed in prisoner-facing roles at the prison (in the Clothing Exchange Store) without any training in self-harm/suicide prevention (in apparent contradiction to the national policy - the Prison Service Instruction 64/2011 in its latest version). Further, one of those staff members was expected to make entries in an (ACCT) support document without having had relevant training. As of October 2017, one of those staff members has still to be trained in self-harm/suicide prevention.
It remains unclear whether the (Carillion) Works Manager and other Carillion supervisors (at a local and national level) are aware of the issue. The prison have since assumed the responsibility for the training of all staff in prisoner-facing roles but there is, as yet, no clarity on the obligations and assumptions which Ministry of Justice and Carillion were operating at the material time (2015-2016) nor indeed what arrangements will pertain in the future . Indeed, I have also heard evidence that the prison do not hold training records for Carillion staff. There is therefore some division of responsibility between the prison and Carillion and a risk that training of staff is missed because of the absence of such records.
I consider there is a risk arising from my investigation that there was and continues to be a gap in training which Carillion is either unaware of or unconcerned with - a gap that may continue here and elsewhere. I understand that Carillion has a contractual obligation to ensure that staff provided to the prison will be appropriately trained, but I cannot identify any requirement for self-harm/suicide management training, nor any commitment by Carillion to make staff available for such training by the prison as necessary. The apparent ambiguities in the arrangement could compromise the safety of prisoners that Carillion personnel are dealing with.
I am also concerned of a risk in other prisons, where Carillion staff are directly engaging with prisoners without adequate or appropriate training in suicide and self-harm management. I invited Carillion to be an Interested Party to the inquest, a request which they declined to take up. Nevertheless, following the evidence in the inquest, the prima facie concerns have hardened. I consider Carillion has the power to take action to remedy these shortcomings and that in collaboration with the Ministry of Justice both can address these concerns and clarify responsibilities.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 control of emergency cell bell misuse
Wider context from the report “3. Emergency Cell Bells
The emergency cell bell (ECB) in Mr Plumstead’s cell had been activated by his cellmate but the response to this took 10.5 minutes whereas the expected response time is 5 minutes. The evidence showed that there was and continues to be widespread misuse of ECB’s by prisoners particularly those on general wings , which leads to prison officers responding on occasions over an hour after the ECB has been activated. There are only limited sanctions available for enforcement of the proper use of the system by prisoners . The system allows no means of prioritising calls or identifying the time when the ECB has been pressed. Prisoners who have a genuine emergency have no alternative means of requesting assistance and therefore the risk is that there medical emergencies will not have a timely response and further deaths in such circumstances will occur. The current system is not fit for purpose and notices to prisoners are ineffective.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 responding to emergency cell bell activations
Wider context from the report “3. Emergency Cell Bells
The emergency cell bell (ECB) in Mr Plumstead’s cell had been activated by his cellmate but the response to this took 10.5 minutes whereas the expected response time is 5 minutes . The evidence showed that there was and continues to be widespread misuse of ECB’s by prisoners particularly those on general wings, which leads to prison officers responding on occasions over an hour after the ECB has been activated . There are only limited sanctions available for enforcement of the proper use of the system by prisoners. The system allows no means of prioritising calls or identifying the time when the ECB has been pressed. Prisoners who have a genuine emergency have no alternative means of requesting assistance and therefore the risk is that there medical emergencies will not have a timely response and further deaths in such circumstances will occur. The current system is not fit for purpose and notices to prisoners are ineffective.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue a national staff learning bulletin on prompt emergency cell bell responses and tackling prisoner misuse.
Verbatim wording from the response “At national level a learning bulletin for staff on the importance of responding promptly to ECBs, and tackling abuse of them by prisoners, will be issued early in 2018.” Source location 2017-0316-Response-by-HM-Prison-Probation-Services.2-1
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 Prepare a funding bid to upgrade the emergency cell bell system.
Verbatim wording from the response “All staff at Winchester have been issued with individual notices about the importance of answering ECBs promptly within the required time. Prisoners have again been issued with information about the risks caused to themselves and others by misuse of ECBs. In addition, the ECB response times are now checked every day in order to improve accountability, and the Governor is preparing a bid for funding to upgrade the ECB system. The range of sanctions available for prisoners misusing ECBs will increase following the rollout of digital in-cell equipment in 2018, as abuse of the ECB system may result in the removal of this equipment.” Source location 2017-0316-Response-by-HM-Prison-Probation-Services.2-1
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 Issue staff notices requiring prompt responses to emergency cell bells.
Verbatim wording from the response “All staff at Winchester have been issued with individual notices about the importance of answering ECBs promptly within the required time. Prisoners have again been issued with information about the risks caused to themselves and others by misuse of ECBs. In addition, the ECB response times are now checked every day in order to improve accountability, and the Governor is preparing a bid for funding to upgrade the ECB system. The range of sanctions available for prisoners misusing ECBs will increase following the rollout of digital in-cell equipment in 2018, as abuse of the ECB system may result in the removal of this equipment.” Source location 2017-0316-Response-by-HM-Prison-Probation-Services.2-1
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 Deliver SASH suicide and self-harm prevention training to new prisoner-facing staff and roll out refresher training to existing staff.
Verbatim wording from the response “The Introduction to Safer Custody course to which this refers was replaced by the Introduction to Suicide and Self-Harm Prevention course, known as SASH, in May 2017. Like its predecessor courses, the SASH course is being delivered to all new prison officers as part of their entry level training, and to all new staff in other prisoner-facing roles. It has also been developed in modular form so that it can be delivered as refresher training to existing staff.” Source location 2017-0316-Response-by-HM-Prison-Probation-Services.2-1
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 Provide HMPPS’s Suicide Prevention Learning Tool through the intranet.
Verbatim wording from the response “You may also be interested to know that HMPPS has worked with Samaritans to develop a Suicide Prevention Learning Tool that is now available on the HMPPS” Source location 2017-0316-Response-by-HM-Prison-Probation-Services.2-1
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 Issue a Service Manager’s Instruction notifying contractors of suicide and self-harm prevention training requirements and contractual obligations.
Verbatim wording from the response “I accept that the requirement for prisoner-facing staff to undertake suicide and self-harm prevention training was not specifically brought to the attention of Carillion when their contract began, and I can confirm that a Service Manager’s Instruction will be issued imminently to ensure that Carillion, and our other contractors, are made aware of the requirement and their contractual obligation to comply with it. Both HMPPS and Carillion are committed to ensuring that all relevant staff are trained as soon as possible.” Source location 2017-0316-Response-by-HM-Prison-Probation-Services.2-1
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 Issue prisoners information about risks arising from misuse of emergency cell bells.
Verbatim wording from the response “All staff at Winchester have been issued with individual notices about the importance of answering ECBs promptly within the required time. Prisoners have again been issued with information about the risks caused to themselves and others by misuse of ECBs. In addition, the ECB response times are now checked every day in order to improve accountability, and the Governor is preparing a bid for funding to upgrade the ECB system. The range of sanctions available for prisoners misusing ECBs will increase following the rollout of digital in-cell equipment in 2018, as abuse of the ECB system may result in the removal of this equipment.” Source location 2017-0316-Response-by-HM-Prison-Probation-Services.2-1
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 Train prisoner-facing Carillion staff and maintain training records for all staff, including directly employed and contracted staff.
Verbatim wording from the response “I can confirm that a number of Carillion staff in prisoner-facing roles at HMP Winchester have been trained, and that records of training delivered to all staff, including those who are not directly employed, are now held. These records do not, however, include information about the internal training programmes of other employers.” Source location 2017-0316-Response-by-HM-Prison-Probation-Services.2-1
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 Check emergency cell bell response times daily to improve accountability.
Verbatim wording from the response “All staff at Winchester have been issued with individual notices about the importance of answering ECBs promptly within the required time. Prisoners have again been issued with information about the risks caused to themselves and others by misuse of ECBs. In addition, the ECB response times are now checked every day in order to improve accountability, and the Governor is preparing a bid for funding to upgrade the ECB system. The range of sanctions available for prisoners misusing ECBs will increase following the rollout of digital in-cell equipment in 2018, as abuse of the ECB system may result in the removal of this equipment.” Source location 2017-0316-Response-by-HM-Prison-Probation-Services.2-1
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 Train additional staff as SASH trainers to increase capacity for course delivery.
Verbatim wording from the response “The targets for the programme of refresher training have been revised to reflect the fact that the new training takes much longer to complete. This, together with the resourcing challenges that the Prison faced during the summer months, and the lack of availability of trainers equipped to deliver the new course means that it is now projected that the new course will have been delivered to all existing staff who have contact with prisoners by the end of September 2018. Additional staff will be trained as trainers in early 2018 in order to facilitate this.” Source location 2017-0316-Response-by-HM-Prison-Probation-Services.2-1
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 Review accounting systems and storage of internal investigation material to identify and rectify weaknesses.
Verbatim wording from the response “As a result of this, the Head of Business Assurance at the prison is carrying out a review of accounting systems and storage of internal investigation material at HMP Winchester with a view to identifying and rectifying areas of weakness.” Source location 2017-0316-Response-by-HM-Prison-Probation-Services
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Refresher-training figures do not mean prisoner-facing staff have never been trained or are deployed unable to recognise suicide and self-harm risk.
Verbatim wording from the response “Crucially, this does not mean that untrained staff who are unable to recognise prisoners at risk are being deployed in the prison. The training targets relate to the completion of the local refresher training. So, whilst the figures that you quote show a temporary reduction in the proportion of staff who are “in date” in terms of the local requirement to have undertaken such training within the last three years, this does not mean that there are staff in prisoner-facing roles who have never been trained. Moreover, the refresher training that the staff are now undertaking is much more extensive, and contains more detailed information about risk, than the ACCT training that was previously available. For this reason I am confident that the changes that have been made to the training programme will have the effect of improving staff awareness and capacity to identify and address risk.” Source location 2017-0316-Response-by-HM-Prison-Probation-Services.2-1
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Refresher-training completion was delayed because the longer course, resourcing challenges and limited availability of qualified trainers constrained delivery.
Verbatim wording from the response “The targets for the programme of refresher training have been revised to reflect the fact that the new training takes much longer to complete. This, together with the resourcing challenges that the Prison faced during the summer months, and the lack of availability of trainers equipped to deliver the new course means that it is now projected that the new course will have been delivered to all existing staff who have contact with prisoners by the end of September 2018. Additional staff will be trained as trainers in early 2018 in order to facilitate this.” Source location 2017-0316-Response-by-HM-Prison-Probation-Services.2-1
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation HMP Winchester had recordings of all telephone calls, although access was restricted because the listening system was encrypted.
Verbatim wording from the response “1) HMP Winchester does have recordings of all telephone calls made by Mr Plumstead and will provide you with a copy as directed. HMP Winchester have always had copies of the calls but the system on which calls are accessed to be listened to is encrypted.” Source location 2017-0316-Response-by-HM-Prison-Probation-Services
Open published response
11 Oct 2017 Mark Daniel VAGNONI · Prevention of Future Deaths report Bedfordshire and Luton
View report summary
Concerns raised 3 Inability to carry out risk assessments with mental health input during patrol state View source Lack of Wing Transfer documentation conveying past ACCTs and risk factors View source NOMIS failing to alert staff to past ACCTs from the initial screen View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mark Daniel VAGNONI · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mark Daniel Vagnoni, who had paranoid schizophrenia and was on remand at HM Prison Bedford, was found hanging in his cell on 11 July 2016 and died two days later. Concerns included the arrangements for risk assessment and observation after an ACCT was opened, the accessibility of information about previous ACCTs in NOMIS, and the lack of Wing Transfer documentation containing relevant risk information.
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 Inability to carry out risk assessments with mental health input during patrol state
Wider context from the report “1. The ACCT was opened during patrol state. The first review was planned the following morning. Apart from 30 minute observations and the information on NOMIS (which was scant) there was no ability to carry out a risk assessment with mental health input. It seems to me that prisoners are especially vulnerable during this patrol state period and greater observations and/or other strategies should be undertaken until the first review can take place.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Lack of Wing Transfer documentation conveying past ACCTs and risk factors
Wider context from the report “3. The jury were also concerned that there appears to be no Wing Transfer documentation , which could have included information about past ACCTs and indeed past 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 NOMIS failing to alert staff to past ACCTs from the initial screen
Wider context from the report “2. The jury expressed concerns that the NOMIS layout were not helpful to staff in that the staff needed to drill down beyond the initial screen to be alerted to past ACCTs
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue Bedford guidance requiring staff to share prisoner risk information during location changes verbally, on NOMIS and in wing observation books, with monthly recording checks.
Verbatim wording from the response “In October 2017 all staff at HMP Bedford were reminded through a Notice to Staff of the importance of ensuring that all available information, including any identified risk factors, must be considered prior to changing a prisoner’s location, and shared with staff responsible for their care at the receiving location. Information must be shared both verbally and on NOMIS, with entries also made in the wing observation book. Residential managers are required to undertake monthly checks on wing observation books and NOMIS to ensure that information is being recorded accurately and comprehensively.” Source location 2017-0286-Response-by-HM-Prison-Probation-Service
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NOMIS provides current alerts and accessible historical ACCT information, with staff training on locating prisoner information.
Verbatim wording from the response “The current layout of NOMIS contains alerts on the home screen which allow staff to see important, current information on a prisoner, including whether they are on an open ACCT. Past information is easily accessible through the prisoner’s history section, and all prison staff who need to access NOMIS are trained in its use before being given access to the system. The course is designed to make staff aware of where and how the information about a prisoner is recorded.” Source location 2017-0286-Response-by-HM-Prison-Probation-Service
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing policy requires recording and sharing prisoner risks and needs before location changes through wing books, NOMIS and verbal communication.
Verbatim wording from the response “As you may be aware, PS1 75/2011 Residential Services requires that any information regarding the needs, risks or behaviours of prisoners who are showing signs of distress or self-harm must be properly recorded in the wing occurrence book or equivalent, and shared appropriately with other teams.” Source location 2017-0286-Response-by-HM-Prison-Probation-Service
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Risk-based ACCT observation levels already account for increased night-state risk when full review and mental-health input are unavailable.
Verbatim wording from the response “Prison Service Instruction 64/2011 Safer Custody states that the level of ACCT observations needs to be set on the basis of a consideration of the level of risk, and with particular regard to any factors which may increase risk, and this would include an inability to undertake a full ACCT case review with mental health input during the night state. National policy also states that observation levels must be clearly documented on the front cover of the ACCT document, with observations made at unpredictable times.” Source location 2017-0286-Response-by-HM-Prison-Probation-Service
Open published response
Concerns raised 2 Failure to place prisoners at risk of suicide or self-harm on an ACCT View source Lack of anti-barricade doors in some prison wings View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Sam MOLYNEUX · 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
Sam Molyneux, a prisoner at HMP Liverpool, was found hanging from a ligature in his cell on 1 April 2016 and was pronounced dead at 22:55. The inquest identified a failure to open an ACCT, concerns about the response to assaults and possible bullying, and a delay in accessing him because the cell door could be barricaded.
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 place prisoners at risk of suicide or self-harm on an ACCT
Wider context from the report “During the course of the inquest it became apparent that in old prisons not all wings have been adapted to have anti-barricade doors. In this case Mr Molyneux had barricaded his door and this delayed prison staff gaining access to him during a Code Blue Situation. He was not on an ACCT but perhaps should have been given his threats of suicide and self-harm articulated by him in a letter to a Governor on an adjudication the day before his death . Local directions in the Prison during the inquest have addressed this situation in HMP Liverpool at Walton. That said HM Prison and Probation service might wish to consider amending “Management of Prisoners at risk of harm to self, to others and from others (Safer Custody)” to include consideration of where reasonably practicable avoiding locating prisoners behind a door which is not designed to circumvent barricading.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 anti-barricade doors in some prison wings
Wider context from the report “During the course of the inquest it became apparent that in old prisons not all wings have been adapted to have anti-barricade doors . In this case Mr Molyneux had barricaded his door and this delayed prison staff gaining access to him during a Code Blue Situation . He was not on an ACCT but perhaps should have been given his threats of suicide and self-harm articulated by him in a letter to a Governor on an adjudication the day before his death. Local directions in the Prison during the inquest have addressed this situation in HMP Liverpool at Walton. That said HM Prison and Probation service might wish to consider amending “Management of Prisoners at risk of harm to self, to others and from others (Safer Custody)” to include consideration of where reasonably practicable avoiding locating prisoners behind a door which is not designed to circumvent barricading.
” 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 Ensure the revised ACCT form and accompanying policy direct staff to consider emergency access, including anti-barricade doors, when locating prisoners on ACCT.
Verbatim wording from the response “Wherever possible, we should avoid using such cells to accommodate prisoners identified as being at risk of self-harm or suicide. As you know, the ACCT process includes consideration by the case review team of the most appropriate location for the prisoner. Both the design of the ACCT form and the content of PSI 64/2011 Safer Custody are currently under review, and we will ensure that the revised version of the form and accompanying policy direct staff to have regard to the issue of emergency access – including the presence of an anti-barricade door – when making decisions about the location of a prisoner on an ACCT. We will also include this in the training that is provided for ACCT case managers.” Source location 2017-0340-Response-by-HM-Prison-Probation-Service
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Include emergency-access and anti-barricade-door considerations in training for ACCT case managers.
Verbatim wording from the response “Wherever possible, we should avoid using such cells to accommodate prisoners identified as being at risk of self-harm or suicide. As you know, the ACCT process includes consideration by the case review team of the most appropriate location for the prisoner. Both the design of the ACCT form and the content of PSI 64/2011 Safer Custody are currently under review, and we will ensure that the revised version of the form and accompanying policy direct staff to have regard to the issue of emergency access – including the presence of an anti-barricade door – when making decisions about the location of a prisoner on an ACCT. We will also include this in the training that is provided for ACCT case managers.” Source location 2017-0340-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 Review the ACCT form and safer custody policy to address emergency access and anti-barricade doors in prisoner-location decisions.
Verbatim wording from the response “Wherever possible, we should avoid using such cells to accommodate prisoners identified as being at risk of self-harm or suicide. As you know, the ACCT process includes consideration by the case review team of the most appropriate location for the prisoner. Both the design of the ACCT form and the content of PSI 64/2011 Safer Custody are currently under review, and we will ensure that the revised version of the form and accompanying policy direct staff to have regard to the issue of emergency access – including the presence of an anti-barricade door – when making decisions about the location of a prisoner on an ACCT. We will also include this in the training that is provided for ACCT case managers.” Source location 2017-0340-Response-by-HM-Prison-Probation-Service
Open published response
28 Jul 2017 SARAH LYNNE REED · Prevention of Future Deaths report London (City)
View report summary
Concerns raised 17 Insufficient information provided to prisoner visitors View source Excessive cancellation of prisoner visits View source Failure of ACCT Review team members to fully review the ACCT document View source Failure to make recorded prisoner observations accessible to all relevant team members View source Failure to complete fitness-to-plead reports and fix a hearing date in a timely manner View source Failure to assign clear responsibility for obtaining fitness-to-plead reports View source Failure to facilitate prisoner visits despite behaviour-related barriers View source Failure to record prisoner observations immediately or as soon as practicable View source Failure to notify community care coordinators of prisoner release View source Failure to conduct ACCT reviews on a multidisciplinary basis View source Inappropriate reduction of observation frequency despite deteriorating mental state View source Failure to communicate the fitness-to-plead purpose of remand to the mental health team View source Delays in holding Care Programme Approach meetings View source Failure to require Duty Governor authorisation for cancelled visits View source Inadequate multidisciplinary participation in CPA meetings View source Inadequate quality and duration of CPA meetings View source Insufficient recording of cancelled visits View source See 14 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
SARAH LYNNE REED · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Sarah Lynne Reed took her own life on 11 January 2016 in a single-occupancy cell at HMP Holloway, using a ligature made from bed linen. The report identifies concerns about delays in obtaining fitness-to-plead reports, management of her medication and deteriorating mental health, inappropriate reduction of observations, delays and deficiencies in care planning, and cancelled visits that contributed to her isolation.
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 information provided to prisoner visitors
Wider context from the report “(18) The Coroner also observes that the information provided to visitors including close family was often short on detail and lacked helpful 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 Excessive cancellation of prisoner visits
Wider context from the report “(14) The jury concluded that the number of cancelled visits was unacceptable , particularly for a prisoner such as Sarah with Emotionally Unstable Personality Disorder where engagement is a principal means of treatment.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure of ACCT Review team members to fully review the ACCT document
Wider context from the report “(9) The jury also found that not all members of the ACCT Review team fully reviewed the ACCT document before making a decision .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 recorded prisoner observations accessible to all relevant team members
Wider context from the report “(10) The jury also found the system of some members of the multi-disciplinary team recording observations which were not accessible to all other members of the team to be ‘detrimental’. For example, many helpful observations about Sarah’s behaviour were recorded in the prison medical notes on SystemOne by doctors and nurses, but they were not accessible to prison officers .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to complete fitness-to-plead reports and fix a hearing date in a timely manner
Wider context from the report “(1) The deceased had been remanded in custody for the sole purpose of the Court obtaining two reports by psychiatrists on her fitness to plead and stand trial. Yet by the time of her death, three months later, this objective had not been achieved and no date for a hearing of the issue had been fixed . It is clear from the evidence that Sarah was uncertain what was happening and when she would be going to 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 assign clear responsibility for obtaining fitness-to-plead reports
Wider context from the report “(4) It was not clear on the evidence who took responsibility for obtaining the reports . The Court had ordered them, but the formal request for the first report, dated 27 October 2015, was (a) directed to HMP Holloway, but (b) sent by email from the Court to an administrative officer employed not by the prison but by the Central and North West London NHS Trust (CNWL) who worked from HMP Holloway. One month later, on 27 November 2015, a psychiatrist employed by CNWL in HMP Holloway wrote back to the Court, apologising for the delay and indicating that the request be directed not to CNWL but to the South London and Maudsley NHS Trust. As a result, by about six weeks after the Court’s order, no psychiatrist had yet agreed to prepare a 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 facilitate prisoner visits despite behaviour-related barriers
Wider context from the report “(17) The Coroner also observes that with a little thought and effort arrangements could be made for a visit to Sarah even when her mental state had affected her behaviour . For example, on one occasion on 2 January 2016 (and apparently on one occasion only), Sarah’s mother was allowed to see Sarah in the adjudication room on the Segregation Unit (where Sarah was then housed). It is clear from the evidence that this visit was helpful to Sarah and that more completed visits would have assisted her . The jury so found.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to record prisoner observations immediately or as soon as practicable
Wider context from the report “(11) In addition the Coroner observes that HMP Holloway maintained a practice of recording observations on prisoners which deviated from the national instruction. According to the national policy Management of prisoners at risk of harm to self, to others and from others (Safer Custody) (PSI 64/2011) observations should be recorded ‘immediately or as soon as practicable thereafter’ . According to the local policy at HMP Holloway, as implemented in this case, any observations at any time need be recorded only at four hour intervals in summary 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 notify community care coordinators of prisoner release
Wider context from the report “(19) There was evidence from Sarah’s care coordinator in the community, a social worker with the START Team, that she was never informed by HMP Holloway of the release of any prisoner whom she had previously supported in the community , despite the care coordinator having close links with the prison, for example visiting prisoners she had supported and sometimes taking part in CPA meetings. The care coordinator said that this would be ‘incredibly helpful’.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct ACCT reviews on a multidisciplinary basis
Wider context from the report “(8) The jury also found that the above decision was not multi-disciplinary , which it should have been (as the senior Governor conceded in evidence).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 reduction of observation frequency despite deteriorating mental state
Wider context from the report “(7) The jury concluded that the decision to reduce the frequency of observations on Sarah Reed at ACCT Review No.4 on 5 January 2016, six days before Sarah’s death, was inappropriate given the clear evidence of the deterioration of her mental state .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 the fitness-to-plead purpose of remand to the mental health team
Wider context from the report “(5) The jury found that the evidence that key members of Sarah’s mental health team in HMP Holloway were unaware that the sole purpose of her remand in custody was for the preparation of fitness to plead reports was ‘incomprehensible’.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 holding Care Programme Approach meetings
Wider context from the report “(12) The jury concluded that the delay in holding a Care Programme Approach (CPA) meeting was unacceptable . The evidence showed that a CPA Meeting for assessing a prisoner’s long-term care should have been held within four weeks from reception . In this case it was held after nine weeks .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 require Duty Governor authorisation for cancelled visits
Wider context from the report “(16) The Governor conceded that the records for cancellations were insufficient and all cancellations should have been sanctioned at the level of Duty Governor (which they were not) and not by staff of lesser seniority.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 multidisciplinary participation in CPA meetings
Wider context from the report “(13) The jury also found that the quality of the meeting was not appropriate. It lasted five minutes and only the nurse care coordinator and community psychiatrist were present with the prisoner.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Inadequate quality and duration of CPA meetings
Wider context from the report “(13) The jury also found that the quality of the meeting was not appropriate . It lasted five minutes and only the nurse care coordinator and community psychiatrist were present with the prisoner.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Insufficient recording of cancelled visits
Wider context from the report “(16) The Governor conceded that the records for cancellations were insufficient and all cancellations should have been sanctioned at the level of Duty Governor (which they were not) and not by staff of lesser seniority.
” 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 visits policy and develop a new framework addressing cancellation, visitor information, rebooking and support for families and friends.
Verbatim wording from the response “Our current policies on visits do not provide specific guidance on the issues that you have raised. They are being reviewed and the issues raised will be considered when the new policy framework, due to be launched in the summer of 2018, is being developed. In accordance with our general approach the framework will include less detailed prescription than the current policy, but it will provide guidance on how best to support families and friends with prison visits, including in relation to the points that you have raised.” Source location 2017-0208-Response-by-NOMS
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Redesign the ACCT document for nationwide reintroduction, including consideration of a summary sheet of observations and conversations.
Verbatim wording from the response “The ACCT document is currently being redesigned with a view to its nationwide re-introduction in early 2018. As part of this redesign, we will consider your suggestion that a summary sheet of ACCT observations and conversations be included.” Source location 2017-0208-Response-by-NOMS
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the new custody offender-management model, including dedicated staff and additional resources to support prisoners’ engagement with services before release.
Verbatim wording from the response “Our service specification ‘Manage the Custodial and Post Release Periods’ is clear that all individuals in custody must have a resettlement plan and that the offender manager must ensure that external agencies are notified of a prisoner’s release. All prisons are expected to adhere to this specification, but I know that it is not fully in place across the estate, and we are currently implementing a new model of offender management in custody. This includes making available additional resources to ensure that there are dedicated staff in each establishment who can provide support to prisoners, including by facilitating their engagement with services prior to release. This is scheduled to be in place in all prisons by March 2019.” Source location 2017-0208-Response-by-NOMS
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue learning bulletins reinforcing multidisciplinary ACCT reviews, required timescales, written contributions and prompt recording of observations.
Verbatim wording from the response “delaying simply to allow a specific person to attend or contribute, it makes clear that there must be continuity of membership of the ACCT multidisciplinary team. The basis for this is that team members can make a meaningful contribution only if they are fully briefed and familiar with the prisoner’s situation. In order to reinforce this message, a learning bulletin (ACCT - Case Reviews, CAREMAPS and Levels of Conversations and Observations) was issued to all prisons in July this year. The bulletin reminded staff that ACCT review meetings must be multidisciplinary and must take place within the specified timescales. It further stated that that where any individual involved in the prisoner’s management cannot attend the review, they must submit written contributions.” Source location 2017-0208-Response-by-NOMS
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review procedures for obtaining and providing psychiatric reports, including fitness-to-plead reports.
Verbatim wording from the response “Work to review the procedures for obtaining and providing psychiatric reports is already underway, recognising the particular gap in relation to provision of reports for the purposes of fitness to plead. Following your letter to ████████, Chief Executive HMCTS, I can confirm that in July 2017 HMCTS and the Judicial Office re-issued existing guidance from 2010 on this process, with the caveat that it is recognised that some information may be out of date. The Senior Presiding Judge has asked the Criminal Procedure Rule Committee to look at this issue with a view to providing greater certainty and clarity for the judiciary and court staff when dealing with psychiatric reports.” Source location 2017-0208-Response-by-NOMS
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation National policy already requires immediate recording of observations and does not permit prisons to adopt conflicting local policies.
Verbatim wording from the response “You ask whether it is acceptable that a prison should be permitted to develop a local policy which is at variance with national policy. I can confirm that it is not. As you rightly state, under national policy, observations should be recorded immediately, or as soon as possible thereafter. I can confirm that this was reiterated in a learning bulletin (ACCT - Conversations and Observations) published in July this year, to which you refer in your report.” Source location 2017-0208-Response-by-NOMS
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Psychiatric-report practice directions and related rules are matters for the independent Criminal Procedure Rule Committee and Lord Chief Justice.
Verbatim wording from the response “The working group will consider new practice directions, and in view of your concerns, it may decide to suggest new rules to govern the procedure on obtaining assessments of fitness to plead, and psychiatric reports for sentencing purposes. Even though listing is a judicial function, the working group may also recommend that new practice directions, or rules, should prescribe default time limits for steps to be taken and progress reviewed, subject to judicial adjustment in individual cases.” Source location 2017-0208-Response-by-NOMS
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 CPA meetings are controlled by healthcare providers, so HMPPS would not necessarily be involved in them.
Verbatim wording from the response “Care Programme Approach (CPA) Meetings
Your next concern is about the scheduling of CPA meetings and attendance at them. Whilst you have directed this concern to HMPPS, CPA meetings are controlled by healthcare providers, and whilst we stand ready to assist where appropriate, we would not necessarily expect to be involved in these meetings. I am aware that the CNWL NHS Foundation Trust has responded to you separately on this point.” Source location 2017-0208-Response-by-NOMS
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation ACCT policy permits reviews and necessary decisions to proceed without waiting for a particular attendee, while requiring multidisciplinary continuity.
Verbatim wording from the response “Whilst national policy acknowledges that in certain circumstances it may be preferable to hold a review and make any necessary decisions promptly, rather than” Source location 2017-0208-Response-by-NOMS
Open published response
Concerns raised 4 Failure to record received prisoner health documentation and its handover to reception healthcare View source Failure to provide nurses with relevant prisoner escort information during first health reception screening View source Delays in completing the second health screening after reception View source Failure of probation staff working in prisons to understand the low threshold for opening an ACCT 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
Edwin Lewis O'Donnell · 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
Edwin Lewis O'Donnell died on 23 October 2016 after being found unresponsive and hanging by a ligature from his cell tap; resuscitation was unsuccessful. The inquest found that his accidental death was contributed to by neglect, including failures to conduct an ACCT review, act on a referral for a mental health assessment, and escalate information that he had said he would be dead by 8.00 p.m.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to record received prisoner health documentation and its handover to reception healthcare
Wider context from the report “During the course of the inquest into the death of Edwin Lewis (Ned) O’Donnell it was apparent that a nurse carrying out the first health reception screening was not given access to the PER (Prisoner Escort Report) which had accompanied the prisoner from another prison establishment.
a) The PER form had content which was pertinent to mental wellbeing which was inconsistent with the information provided by Ned.
b) Though the previous prison indicated that they had sent a print from the digital IMR System One the nurse conducting the first health reception screening had no recollection or notes to indicate whether this was available at the time of the screening.
c) There is expected to be a second health screening of inmates some 24 to 48 hours later – which enables information from the community to be received and fuller informed access to the digital IMR System One. In this case the second screening was not until the 27th March 2016. Whereas the first screening was on the 9th March 2016.
d) An offender supervisor (Probation) working in the prison has been ACCT trained but did not know that there was a low threshold for opening an ACCT
The Court considers that in other cases important information in assessing risk could be missed if action is not taken to remedy these matters by making it a requirement that prison discipline staff record on C-Nomis all documentation received with a prisoner in particular
• PER forms
• SASH forms
• Printed summaries from System One
• Prescriptions
C-Nomis should also be noted that these have been handed to (or copies have been handed to healthcare in reception.
It could also be a mandated requirement that the digital IMR System One be updated (possibly when the digital IMR System Two is rolled out if that is imminent) with forced fields to ensure that nurses carrying out the first health reception screening record the documentation provided by the Prison staff which accompanied the prisoner.
The Court has heard evidence of the new training developed for the ACCT protocol and that this is being rolled out in a prioritised manner within HMP Liverpool. The Court considers it important that the Probation service takes responsibility to ensure that (offender managers and supervisors) probation staff working within prisons all receive basic ACCT training. Probation staff often have to break unwelcome news and this must require a risk assessment of the effects of that news on inmates.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 nurses with relevant prisoner escort information during first health reception screening
Wider context from the report “During the course of the inquest into the death of Edwin Lewis (Ned) O’Donnell it was apparent that a nurse carrying out the first health reception screening was not given access to the PER (Prisoner Escort Report) which had accompanied the prisoner from another prison establishment.
a) The PER form had content which was pertinent to mental wellbeing which was inconsistent with the information provided by Ned.
b) Though the previous prison indicated that they had sent a print from the digital IMR System One the nurse conducting the first health reception screening had no recollection or notes to indicate whether this was available at the time of the screening.
c) There is expected to be a second health screening of inmates some 24 to 48 hours later – which enables information from the community to be received and fuller informed access to the digital IMR System One. In this case the second screening was not until the 27th March 2016. Whereas the first screening was on the 9th March 2016.
d) An offender supervisor (Probation) working in the prison has been ACCT trained but did not know that there was a low threshold for opening an ACCT
The Court considers that in other cases important information in assessing risk could be missed if action is not taken to remedy these matters by making it a requirement that prison discipline staff record on C-Nomis all documentation received with a prisoner in particular
• PER forms
• SASH forms
• Printed summaries from System One
• Prescriptions
C-Nomis should also be noted that these have been handed to (or copies have been handed to healthcare in reception.
It could also be a mandated requirement that the digital IMR System One be updated (possibly when the digital IMR System Two is rolled out if that is imminent) with forced fields to ensure that nurses carrying out the first health reception screening record the documentation provided by the Prison staff which accompanied the prisoner.
The Court has heard evidence of the new training developed for the ACCT protocol and that this is being rolled out in a prioritised manner within HMP Liverpool. The Court considers it important that the Probation service takes responsibility to ensure that (offender managers and supervisors) probation staff working within prisons all receive basic ACCT training. Probation staff often have to break unwelcome news and this must require a risk assessment of the effects of that news on inmates.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 the second health screening after reception
Wider context from the report “During the course of the inquest into the death of Edwin Lewis (Ned) O’Donnell it was apparent that a nurse carrying out the first health reception screening was not given access to the PER (Prisoner Escort Report) which had accompanied the prisoner from another prison establishment.
a) The PER form had content which was pertinent to mental wellbeing which was inconsistent with the information provided by Ned.
b) Though the previous prison indicated that they had sent a print from the digital IMR System One the nurse conducting the first health reception screening had no recollection or notes to indicate whether this was available at the time of the screening.
c) There is expected to be a second health screening of inmates some 24 to 48 hours later – which enables information from the community to be received and fuller informed access to the digital IMR System One. In this case the second screening was not until the 27th March 2016. Whereas the first screening was on the 9th March 2016.
d) An offender supervisor (Probation) working in the prison has been ACCT trained but did not know that there was a low threshold for opening an ACCT
The Court considers that in other cases important information in assessing risk could be missed if action is not taken to remedy these matters by making it a requirement that prison discipline staff record on C-Nomis all documentation received with a prisoner in particular
• PER forms
• SASH forms
• Printed summaries from System One
• Prescriptions
C-Nomis should also be noted that these have been handed to (or copies have been handed to healthcare in reception.
It could also be a mandated requirement that the digital IMR System One be updated (possibly when the digital IMR System Two is rolled out if that is imminent) with forced fields to ensure that nurses carrying out the first health reception screening record the documentation provided by the Prison staff which accompanied the prisoner.
The Court has heard evidence of the new training developed for the ACCT protocol and that this is being rolled out in a prioritised manner within HMP Liverpool. The Court considers it important that the Probation service takes responsibility to ensure that (offender managers and supervisors) probation staff working within prisons all receive basic ACCT training. Probation staff often have to break unwelcome news and this must require a risk assessment of the effects of that news on inmates.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 working in prisons to understand the low threshold for opening an ACCT
Wider context from the report “During the course of the inquest into the death of Edwin Lewis (Ned) O’Donnell it was apparent that a nurse carrying out the first health reception screening was not given access to the PER (Prisoner Escort Report) which had accompanied the prisoner from another prison establishment.
a) The PER form had content which was pertinent to mental wellbeing which was inconsistent with the information provided by Ned.
b) Though the previous prison indicated that they had sent a print from the digital IMR System One the nurse conducting the first health reception screening had no recollection or notes to indicate whether this was available at the time of the screening.
c) There is expected to be a second health screening of inmates some 24 to 48 hours later – which enables information from the community to be received and fuller informed access to the digital IMR System One. In this case the second screening was not until the 27th March 2016. Whereas the first screening was on the 9th March 2016.
d) An offender supervisor (Probation) working in the prison has been ACCT trained but did not know that there was a low threshold for opening an ACCT
The Court considers that in other cases important information in assessing risk could be missed if action is not taken to remedy these matters by making it a requirement that prison discipline staff record on C-Nomis all documentation received with a prisoner in particular
• PER forms
• SASH forms
• Printed summaries from System One
• Prescriptions
C-Nomis should also be noted that these have been handed to (or copies have been handed to healthcare in reception.
It could also be a mandated requirement that the digital IMR System One be updated (possibly when the digital IMR System Two is rolled out if that is imminent) with forced fields to ensure that nurses carrying out the first health reception screening record the documentation provided by the Prison staff which accompanied the prisoner.
The Court has heard evidence of the new training developed for the ACCT protocol and that this is being rolled out in a prioritised manner within HMP Liverpool. The Court considers it important that the Probation service takes responsibility to ensure that (offender managers and supervisors) probation staff working within prisons all receive basic ACCT training . Probation staff often have to break unwelcome news and this must require a risk assessment of the effects of that news on inmates.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide reception healthcare staff with Person Escort Records, brief relevant staff, and conduct spot checks of compliance.
Verbatim wording from the response “Information Sharing and Recording
Your first concern is that the member of healthcare staff carrying out the first health screening for Mr O’Donnell did not have access to the Person Escort Record (PER). Following the investigation into Mr O’Donnell’s death, the Governor tasked the Heads of Operations and Healthcare at the prison with devising a process to address this. The Senior Officer in reception now provides a copy of the Person Escort Record (PER) to the healthcare member of staff based there, ensuring that they have access to all the relevant information. All reception staff, and healthcare staff who may work in reception, have been made aware of this process, and the Head of Operations carries out spot checks to ensure that it is being followed.” Source location 2017-0258-Response-by-HM-Prison-Probation-Service
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Send an additional Person Escort Record copy to Safer Custody for cross-checking against NOMIS information.
Verbatim wording from the response “The operation of this system is assured by the Head of Operations, and an additional copy of the PER is sent to the Safer Custody department who cross-reference it with the information held on NOMIS to ensure that nothing has been missed.” Source location 2017-0258-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 Roll out revised suicide and self-harm prevention training to staff with prisoner contact, including probation officers, through Liverpool’s twice-monthly training days.
Verbatim wording from the response “You have drawn attention to the importance of training for probation officers, and I noted that HMPPS is rolling out revised suicide and self-harm training for staff. I can reassure you that this training is being rolled out at pace to all staff with prisoner contact, including probation officers. At Liverpool the training is being delivered at the ‘Academy Training Days’ which take place twice monthly.” Source location 2017-0258-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 Re-evaluate current practices and implement revised procedures to ensure second health screenings occur within 24–48 hours.
Verbatim wording from the response “Timing of the Second Health Screening
Your second concern relates to the delay in Mr O’Donnell’s second health screening. I understand that the Head of Healthcare at Liverpool and a member of the prison’s senior management team are meeting shortly to re-evaluate current practices and implement revised procedures to ensure that second health screenings take place within 24-48 hours.” Source location 2017-0258-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 Existing information-sharing arrangements make recording receipt of documents on NOMIS unnecessary.
Verbatim wording from the response “In addition, you have suggested that receipt of the PER, Suicide and Self Harm forms, prints from SystmOne (the electronic patient record) and prescriptions should be recorded on NOMIS, and that a note should be made on NOMIS that copies of the documents have been handed to healthcare staff in reception. This would be time consuming for reception staff, and could involve changes to the NOMIS system that would come with a cost. On the basis that the system for sharing information with healthcare staff described above has been implemented, and that a PER is received with every prisoner who arrives at the prison, we do not believe it to be necessary to make these notes on NOMIS.” Source location 2017-0258-Response-by-HM-Prison-Probation-Service
Open published response
Concerns raised 2 Failure to ensure responding staff have basic resuscitation training View source Lack of Prison Officer training on differences in the night/patrol state 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
Ondrej SUHA · 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
Ondrej Suha, a serving prisoner, was found hanging in his cell on 21 December 2015 and died in hospital on 25 December 2015. Concerns included the lack of specific night-shift training for the responding prison officer and the absence of first-aid training enabling initial staff to attempt resuscitation.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure responding staff have basic resuscitation training
Wider context from the report “(2) The initial staff responding to the incident did not have first aid training to enable them to attempt resuscitation . Subsequently many staff at HMPOI Brinsford have had this training. However I wonder if basic resuscitation should form part of a Prison Officer's training or indeed if the quotas for staff on duty at any one time in a prison with such training should be reviewed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 on differences in the night/patrol state
Wider context from the report “(1) Ondrej was discovered hanging in his cell soon after 9pm. In his evidence the Prison officer who was involved in the initial response indicated that he had just started his first night shift (he was experienced with day shifts) but had no specific training for this . I wonder if standard training for Prison Officers should include some limited information about differences in the regime when the prison is in the night/patrol state .
” Open source report
Concerns raised 7 Failure to perform regular and timely validation visits View source Failure to refer or admit high risk offenders only to accommodation capable of appropriately managing their risks View source Failure to exercise influence and oversight over supported living accommodation and probation services View source Failure to provide timely, accurate and up to date offender information View source Failure to verify procedures for effective service delivery and public protection View source Failure to review and revise risk assessments dynamically View source Failure to recall offenders to prison or prevent referral to unsuitable supported living accommodation View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
John Clarke Jaundoo · 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 Clarke Jaundoo, aged 24, was found with multiple stab wounds under Garston Bridge in the early hours of 15 April 2010 and died later in hospital. Three men who lived in the same supported living accommodation were subsequently convicted of his murder, and the inquest concluded that he died as a result of unlawful killing. The inquiry identified concerns about the referral and accommodation of high-risk offenders, failures to provide accurate and up-to-date information and review risk assessments, and missed oversight opportunities by Liverpool City Council.
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 perform regular and timely validation visits
Wider context from the report “In respect of the then Probation Trust
(1) Offender 2 should have been recalled to prison and not referred to or accepted into supported living accommodation, it was wholly unsuitable for him and in particular when his behaviour was deteriorating to such an extent in the Approved Premises that his bed was withdrawn.
(2) Offender 3 a high risk offender should never have been referred to or admitted to supported living accommodation (upon his release from prison), the only suitable accommodation where the risks that he posed could be appropriately managed being Approved Premises.
(3) Timely, accurate and up to date information was not provided in respect of offenders 2 & 3 and;
(4) The risk assessment which should have been a dynamic process was not reviewed/revised in particular as it should have been in respect of offender 2 when his behaviour started to deteriorate so substantially and which also included alcohol consumption a known precursor to his offending.
In respect of Liverpool City Council (Adult Social Services)
(1) Missed a number of significant opportunities to properly exercise their influence and oversight function of both the then supported living accommodation provider and the Probation Trust, they also missed opportunities to perform regular, timely validation visits and to satisfy themselves of the procedures that were in place to ensure the aims of the service were being effectively delivered and that public protection (including of staff and other service users) was the overriding priority.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 or admit high risk offenders only to accommodation capable of appropriately managing their risks
Wider context from the report “In respect of the then Probation Trust
(1) Offender 2 should have been recalled to prison and not referred to or accepted into supported living accommodation, it was wholly unsuitable for him and in particular when his behaviour was deteriorating to such an extent in the Approved Premises that his bed was withdrawn.
(2) Offender 3 a high risk offender should never have been referred to or admitted to supported living accommodation (upon his release from prison), the only suitable accommodation where the risks that he posed could be appropriately managed being Approved Premises .
(3) Timely, accurate and up to date information was not provided in respect of offenders 2 & 3 and;
(4) The risk assessment which should have been a dynamic process was not reviewed/revised in particular as it should have been in respect of offender 2 when his behaviour started to deteriorate so substantially and which also included alcohol consumption a known precursor to his offending.
In respect of Liverpool City Council (Adult Social Services)
(1) Missed a number of significant opportunities to properly exercise their influence and oversight function of both the then supported living accommodation provider and the Probation Trust, they also missed opportunities to perform regular, timely validation visits and to satisfy themselves of the procedures that were in place to ensure the aims of the service were being effectively delivered and that public protection (including of staff and other service users) was the overriding priority.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 exercise influence and oversight over supported living accommodation and probation services
Wider context from the report “In respect of the then Probation Trust
(1) Offender 2 should have been recalled to prison and not referred to or accepted into supported living accommodation, it was wholly unsuitable for him and in particular when his behaviour was deteriorating to such an extent in the Approved Premises that his bed was withdrawn.
(2) Offender 3 a high risk offender should never have been referred to or admitted to supported living accommodation (upon his release from prison), the only suitable accommodation where the risks that he posed could be appropriately managed being Approved Premises.
(3) Timely, accurate and up to date information was not provided in respect of offenders 2 & 3 and;
(4) The risk assessment which should have been a dynamic process was not reviewed/revised in particular as it should have been in respect of offender 2 when his behaviour started to deteriorate so substantially and which also included alcohol consumption a known precursor to his offending.
In respect of Liverpool City Council (Adult Social Services)
(1) Missed a number of significant opportunities to properly exercise their influence and oversight function of both the then supported living accommodation provider and the Probation Trust , they also missed opportunities to perform regular, timely validation visits and to satisfy themselves of the procedures that were in place to ensure the aims of the service were being effectively delivered and that public protection (including of staff and other service users) was the overriding priority.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to provide timely, accurate and up to date offender information
Wider context from the report “In respect of the then Probation Trust
(1) Offender 2 should have been recalled to prison and not referred to or accepted into supported living accommodation, it was wholly unsuitable for him and in particular when his behaviour was deteriorating to such an extent in the Approved Premises that his bed was withdrawn.
(2) Offender 3 a high risk offender should never have been referred to or admitted to supported living accommodation (upon his release from prison), the only suitable accommodation where the risks that he posed could be appropriately managed being Approved Premises.
(3) Timely, accurate and up to date information was not provided in respect of offenders 2 & 3 and;
(4) The risk assessment which should have been a dynamic process was not reviewed/revised in particular as it should have been in respect of offender 2 when his behaviour started to deteriorate so substantially and which also included alcohol consumption a known precursor to his offending.
In respect of Liverpool City Council (Adult Social Services)
(1) Missed a number of significant opportunities to properly exercise their influence and oversight function of both the then supported living accommodation provider and the Probation Trust, they also missed opportunities to perform regular, timely validation visits and to satisfy themselves of the procedures that were in place to ensure the aims of the service were being effectively delivered and that public protection (including of staff and other service users) was the overriding priority.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to verify procedures for effective service delivery and public protection
Wider context from the report “In respect of the then Probation Trust
(1) Offender 2 should have been recalled to prison and not referred to or accepted into supported living accommodation, it was wholly unsuitable for him and in particular when his behaviour was deteriorating to such an extent in the Approved Premises that his bed was withdrawn.
(2) Offender 3 a high risk offender should never have been referred to or admitted to supported living accommodation (upon his release from prison), the only suitable accommodation where the risks that he posed could be appropriately managed being Approved Premises.
(3) Timely, accurate and up to date information was not provided in respect of offenders 2 & 3 and;
(4) The risk assessment which should have been a dynamic process was not reviewed/revised in particular as it should have been in respect of offender 2 when his behaviour started to deteriorate so substantially and which also included alcohol consumption a known precursor to his offending.
In respect of Liverpool City Council (Adult Social Services)
(1) Missed a number of significant opportunities to properly exercise their influence and oversight function of both the then supported living accommodation provider and the Probation Trust, they also missed opportunities to perform regular, timely validation visits and to satisfy themselves of the procedures that were in place to ensure the aims of the service were being effectively delivered and that public protection (including of staff and other service users) was the overriding priority .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 revise risk assessments dynamically
Wider context from the report “In respect of the then Probation Trust
(1) Offender 2 should have been recalled to prison and not referred to or accepted into supported living accommodation, it was wholly unsuitable for him and in particular when his behaviour was deteriorating to such an extent in the Approved Premises that his bed was withdrawn.
(2) Offender 3 a high risk offender should never have been referred to or admitted to supported living accommodation (upon his release from prison), the only suitable accommodation where the risks that he posed could be appropriately managed being Approved Premises.
(3) Timely, accurate and up to date information was not provided in respect of offenders 2 & 3 and;
(4) The risk assessment which should have been a dynamic process was not reviewed/revised in particular as it should have been in respect of offender 2 when his behaviour started to deteriorate so substantially and which also included alcohol consumption a known precursor to his offending.
In respect of Liverpool City Council (Adult Social Services)
(1) Missed a number of significant opportunities to properly exercise their influence and oversight function of both the then supported living accommodation provider and the Probation Trust, they also missed opportunities to perform regular, timely validation visits and to satisfy themselves of the procedures that were in place to ensure the aims of the service were being effectively delivered and that public protection (including of staff and other service users) was the overriding priority.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 recall offenders to prison or prevent referral to unsuitable supported living accommodation
Wider context from the report “In respect of the then Probation Trust
(1) Offender 2 should have been recalled to prison and not referred to or accepted into supported living accommodation , it was wholly unsuitable for him and in particular when his behaviour was deteriorating to such an extent in the Approved Premises that his bed was withdrawn.
(2) Offender 3 a high risk offender should never have been referred to or admitted to supported living accommodation (upon his release from prison), the only suitable accommodation where the risks that he posed could be appropriately managed being Approved Premises.
(3) Timely, accurate and up to date information was not provided in respect of offenders 2 & 3 and;
(4) The risk assessment which should have been a dynamic process was not reviewed/revised in particular as it should have been in respect of offender 2 when his behaviour started to deteriorate so substantially and which also included alcohol consumption a known precursor to his offending.
In respect of Liverpool City Council (Adult Social Services)
(1) Missed a number of significant opportunities to properly exercise their influence and oversight function of both the then supported living accommodation provider and the Probation Trust, they also missed opportunities to perform regular, timely validation visits and to satisfy themselves of the procedures that were in place to ensure the aims of the service were being effectively delivered and that public protection (including of staff and other service users) was the overriding priority.
” Open source report
Concerns raised 9 Failure to follow up missed second reception screens View source Insufficient training and experience to explore mental health and substance-use issues View source Lack of first aid and CPR training for prison officers View source Failure of prison officers to understand ACCT contents View source Failure of prison officers to understand code blue and code red distinctions View source Failure to accurately record self-harm or suicide assessments View source Failure to make mental health team referrals View source Failure to conduct the second reception screen View source Failure to review and record events in the ACCT document View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
John WILLIAMS · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
John Williams hanged himself while he was a prisoner at HM Prison Pentonville, after telling staff that he would do so if his perceived needs were not met rather than intending to take his life. Concerns included inaccuracies and omissions in reception screening and referrals, inadequate understanding and use of the ACCT document, insufficient training for some support staff, confusion about emergency codes, and a lack of basic first aid and CPR training among 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 follow up missed second reception screens
Wider context from the report “2. There was no second reception screen conducted. If Mr Williams was not brought to healthcare staff for his second reception screen then healthcare staff needed to follow this up .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Insufficient training and experience to explore mental health and substance-use issues
Wider context from the report “5. Mr Williams also told the member of Phoenix Futures who saw him that he felt cannabis gave him what the mental health team did not. However, the staff member felt he did not have the training or experience to explore either of these issues in greater depth .
It may be that Phoenix Futures staff would benefit from additional training, perhaps alongside prison healthcare staff.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Lack of first aid and CPR training for prison officers
Wider context from the report “7. The prison officers did not have even the most basic first aid and cardiopulmonary resuscitation (CPR) training . I am aware from other inquests that this is not provided at a national level.
I have written about this before. It seems a significant gap, even allowing for the fact that there are always two trained nurses on site.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure of prison officers to understand ACCT contents
Wider context from the report “4. Mr Williams said to several members of staff that he would self harm or hang himself if he wanted something done and it was not happening quickly enough (rather than because he actually wanted to die.)
This was recorded on his assessment, care in custody, teamwork (ACCT) document. Some prison officers did not seem familiar with the very important contents of the ACCT, not even those inside cover .
The senior officer in charge on the weekend of Mr Williams’ death did not look at the inside cover or record any events within. Again, It appears there may be benefit in additional training and/or supervision.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure of prison officers to understand code blue and code red distinctions
Wider context from the report “6. The issue of the difference between a code blue and a code red is one about which I have written before.
One senior prison officer said in evidence that if she did not know the difference between a code blue and a code red , then there would be some serious concerns. She did not.
She had been given a small card describing code blue and code red (a card which another officer kept about her person and even produced from the witness box), and she still retained that card. However, she had never considered it worthwhile to read .
She said in court that she still thought it appropriate that she had never read the card.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 self-harm or suicide assessments
Wider context from the report “1. The first reception nurse who saw Mr Williams when he entered HMP Pentonville gave evidence that he had no thoughts of self harm or suicide, but she recorded that he had .
It appears she may benefit from additional training and/or supervision.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 mental health team referrals
Wider context from the report “3. The first reception nurse did not make the referral to the mental health team (though this took place in any event because the court diversion team had already made the referral).
I heard that it is now done automatically when that box is ticked on the system, and I wonder whether other prison healthcare providers would benefit from such a system.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 the second reception screen
Wider context from the report “2. There was no second reception screen conducted . If Mr Williams was not brought to healthcare staff for his second reception screen then healthcare staff needed to follow this up.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 events in the ACCT document
Wider context from the report “4. Mr Williams said to several members of staff that he would self harm or hang himself if he wanted something done and it was not happening quickly enough (rather than because he actually wanted to die.)
This was recorded on his assessment, care in custody, teamwork (ACCT) document. Some prison officers did not seem familiar with the very important contents of the ACCT, not even those inside cover.
The senior officer in charge on the weekend of Mr Williams’ death did not look at the inside cover or record any events within . Again, It appears there may be benefit in additional training and/or supervision.
” Open source report
Concerns raised 8 Failure of the admissions protocol to allow transfer of mentally disordered people from police custody View source Failure to meaningfully involve families in the ACCT process View source Insufficient resilience of psychiatric cover at Chelmsford prison View source Failure to provide effective ACCT process training View source Lack of a written record of the forensic pathway View source Failure to formally record concerns raised by a prisoner’s family View source Failure to communicate concerns raised by a prisoner’s family View source Lack of clarity in the hospital transfer process 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
Dean Gary Saunders · 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
Dean Gary Saunders was found unresponsive in his cell at HM Prison Chelmsford on 4 January 2016, and his death was confirmed as electrocution. The inquest identified serious failings in mental health assessment and care, the prison transfer pathway, ACCT assessments and observations, record-keeping and communication, clinical leadership, and family involvement.
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 admissions protocol to allow transfer of mentally disordered people from police custody
Wider context from the report “1. FOR SEPT:- The admitted lacuna in the SEPT admissions protocol governing the transfer of mentally disordered people from police custody . The current admissions protocol does not allow for the transfer of any individual from police custody , irrespective of the criminal charges the individual is facing.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 meaningfully involve families in the ACCT process
Wider context from the report “6. FOR NOMS:- The meaningful involvement of families in the ACCT process , including by ensuring the formal recording, and communication of concerns raised by a prisoner’s family.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Insufficient resilience of psychiatric cover at Chelmsford prison
Wider context from the report “5. FOR NHS ENGLAND:- The resilience of psychiatric cover at Chelmsford prison , which would need to be raised with NHS England who commission such services and decide on the budget.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 effective ACCT process training
Wider context from the report “4. FOR NOMS:- Training regarding the ACCT process . In previous prison deaths and in response to previous PPO reports, promises have been made about training having been provided to staff yet the same mistakes are being repeated . Meaningful action in required in this regard.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 record of the forensic pathway
Wider context from the report “2. FOR SEPT AND NHS ENGLAND:- The absence of a written record of the “best practice” forensic pathway referred to by ████████ in his evidence, and consideration of whether the transfer of individuals such as Dean to prison is indeed “best practice”, taking into account the consequent delay in transfer and the suitability of the prison environment for mentally disordered individuals.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 formally record concerns raised by a prisoner’s family
Wider context from the report “6. FOR NOMS:- The meaningful involvement of families in the ACCT process, including by ensuring the formal recording , and communication of concerns raised by a prisoner’s family .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate concerns raised by a prisoner’s family
Wider context from the report “6. FOR NOMS:- The meaningful involvement of families in the ACCT process, including by ensuring the formal recording, and communication of concerns raised by a prisoner’s family .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity in the hospital transfer process
Wider context from the report “3. FOR CARE UK, NOMS, SEPT:- The lack of clarity regarding the hospital transfer process . The evidence at the inquest demonstrated that this is currently shrouded in confusion and contradiction (if the PSI and the NHS England “good practice” is compared). Given that rationalisation of the process is still a “work in progress”, the family consider that it should be given urgent consideration.
” Open source report
Concerns raised 2 Failure to recognise increased risk from persistently unusual behaviour View source Failure to use appropriate language when describing situations for risk assessment View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Margaret Atkinson · 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
Margaret Atkinson, who had a long history of mental health illness and was in prison healthcare, was found unresponsive in her cell on 24 January 2016 after staff observed clothing around her neck and delayed entering the cell; she died in hospital on 2 February 2016. The jury found that staff should have entered earlier, and the report identified difficulties in describing such situations and assessing risk when unusual behaviour had become accepted as normal.
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 recognise increased risk from persistently unusual behaviour
Wider context from the report “(1) The case revealed issues and difficulties about how situations were described and the choice of appropriate language with the corresponding difficulties resulting therefrom in assessing risk. Furthermore, as there was unusual behaviour over an extended period of time there was an acceptance of such behaviour as being normal and would not be considered as illustrative of increased risk unless there was a significant departure from that already unusual (or bizarre behaviour as it was described in evidence). HMP Low Newton have issued interim guidance to endeavour to address the matter and G4S likewise. A copy of the G4S guidance is attached. This appears good, I believe it needs to be shared throughout the prisoner state generally and not just in the North East cluster of prisons where G4S provides healthcare.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to use appropriate language when describing situations for risk assessment
Wider context from the report “(1) The case revealed issues and difficulties about how situations were described and the choice of appropriate language with the corresponding difficulties resulting therefrom in assessing risk . Furthermore, as there was unusual behaviour over an extended period of time there was an acceptance of such behaviour as being normal and would not be considered as illustrative of increased risk unless there was a significant departure from that already unusual (or bizarre behaviour as it was described in evidence). HMP Low Newton have issued interim guidance to endeavour to address the matter and G4S likewise. A copy of the G4S guidance is attached. This appears good, I believe it needs to be shared throughout the prisoner state generally and not just in the North East cluster of prisons where G4S provides healthcare.
” Open source report
Concerns raised 2 Failure to specify and plan the support to be offered by staff View source Failure to open an ACCT for a person likely to be upset View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Michelle Barnes · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Michelle Barnes was found dead in her cell at HMP Low Newton on 16 December 2015, five days after giving birth and three days after returning to prison. The report identified concerns that an ACCT was not opened after she was told her child would be taken into care, that the support to be offered was not clearly defined or documented, and that other factors probably contributed to her death according to the inquest.
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 specify and plan the support to be offered by staff
Wider context from the report “After the prisoner made a decision to prevent Michelle from further visiting her child in hospital, two officers who did not know Michelle and who Michelle did not know particularly well, were tasked to tell Michelle the news and to further confirm her child was to be taken into care. The senior of those officers, chose not to open an ACCT, notwithstanding she described Michelle as being very upset and crying but instead made an entry in the wing observation book that staff were to “offer support”. It should have been clear to all that Michelle was likely to be upset upon receiving such news. Nothing was documented to indicate or to explain what “support” could or should be offered by staff. There was no clear plan as to what the officer meant by the entry or to what should be delivered. Is there some means of offering support short of an ACCT, was an issue raised by the evidence.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 open an ACCT for a person likely to be upset
Wider context from the report “After the prisoner made a decision to prevent Michelle from further visiting her child in hospital, two officers who did not know Michelle and who Michelle did not know particularly well, were tasked to tell Michelle the news and to further confirm her child was to be taken into care. The senior of those officers, chose not to open an ACCT, notwithstanding she described Michelle as being very upset and crying but instead made an entry in the wing observation book that staff were to “offer support”. It should have been clear to all that Michelle was likely to be upset upon receiving such news . Nothing was documented to indicate or to explain what “support” could or should be offered by staff. There was no clear plan as to what the officer meant by the entry or to what should be delivered. Is there some means of offering support short of an ACCT, was an issue raised by the evidence.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remind ACCT case managers to open and accurately record ACCT documents and use multidisciplinary reviews when prisoners are at risk.
Verbatim wording from the response “ACCT case managers at Low Newton were reminded in November 2016 of the importance of opening an ACCT document when a prisoner is at risk of suicide or self-harm, and the importance of recording this accurately and clearly, and making sure there is a multi-disciplinary approach to ACCT reviews.” Source location Michelle-Barnes-R
Open published response
×
Source 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 and provide refresher training on delivering difficult news to prisoners with children or babies.
Verbatim wording from the response “It is fully recognised that thorough consideration must be given to how distressing news is given to prisoners in such situations, and appropriate action has been taken to ensure that this is appropriately undertaken in the future. Guidance was issued to Low Newton staff in December 2016 about the procedures for delivering difficult news to prisoners with children or babies. Where the mother is pre-natal it instructs staff who are informed of potentially upsetting news to refer this to the pregnancy pathway to ensure that the appropriate staff member, who is known to the prisoner and best placed to deliver the news, is involved. The decision on the timing and delivery of the message will initially be made by the Duty Governor. Annual Refresher Safer Custody training provided to staff includes the new guidelines on delivering difficult news to mothers of babies or young children.” Source location Michelle-Barnes-R
Open published response
×
Source 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 multidisciplinary pregnancy pathway meetings, develop post-birth care plans, and allocate a continuity-of-care coordinator for each pregnant prisoner.
Verbatim wording from the response “The needs of pregnant women are considered at the weekly, multi-disciplinary pregnancy pathway meetings. Attendees are responsible for drawing up and reviewing a care plan for each pregnant woman, detailing what will happen after the birth and how the mother will be supported emotionally and practically, particularly if their baby is removed from their care. The care plan will take into account input from a number of professions, ensuring the most appropriate care plan is put into place for mother and baby. A lead co-ordinator, already familiar with the prisoner, is allocated to support the prisoner throughout the pregnancy, providing continuity of care and ensuring an understanding of their individual circumstances.” Source location Michelle-Barnes-R
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue and disseminate national guidance on multidisciplinary working and ACCT to support continuity of care.
Verbatim wording from the response “In order to improve joined-up working to manage and support prisoners at risk of suicide or self-harm, new guidance around multi-disciplinary working and ACCT was issued by NOMS in October 2016 and disseminated to all prisons. The guidance aims to ensure that professionals carefully consider a prisoner’s needs and that they are provided with continuity of care, even when support will be delivered by different individuals or providers.” Source location Michelle-Barnes-R
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 ACCT is intended for identified suicide or self-harm risk, while general distress is addressed through other existing support mechanisms.
Verbatim wording from the response “You express concern that safer custody practices do not consider prisoners in a holistic manner. As you are aware, prisoners considered at risk of suicide and self-harm are managed through the ACCT process. The review of ACCT process undertaken in 2015, found that the policy and system are sound, but that work is needed on improving compliance with policy and the quality of delivery of care. It is recognised that when used effectively ACCT is a holistic tool, bringing together multi-disciplinary teams to contribute to the management of an individual’s risk, which may include mental health concerns, substance abuse and a range of other factors. The other support mechanisms described above also form part of the holistic approach, alongside everyday interaction, support and challenge by staff.” Source location Michelle-Barnes-R
Open published response
Concerns raised 1 Failure to provide cause for concern line details to visitors and family members 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
Simon John Turvey · 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
Simon John Turvey was found hanging in his locked cell at HMP Woodhill on 29 December 2015 and was declared dead by paramedics. The concerns included failures in the Personal Officer scheme and a lack of proactive communication to family members about how to share concerns with the prison, meaning risk factors may have been missed.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to provide cause for concern line details to visitors and family members
Wider context from the report “1. That the details of the cause for concern line should be given to all visitor and family members so that they can easily report their concerns to the prison.
” Open source report
Concerns raised 15 Ineffective chest compressions during CPR View source Failure to assess breathing and perform airway manoeuvres during resuscitation View source Unavailability of a serviceable oxygen cylinder during resuscitation View source Failure of emergency healthcare lead nurses to understand code red and code blue medical emergencies View source Failure to distinguish cardiorespiratory arrest from unconsciousness during emergency assessment View source Delay in providing substantive resuscitation care after nurse arrival View source Failure to explore recorded history of depression during reception screening View source Failure to record circumstances of the index offence in the healthcare record View source Failure to obtain general practitioner records View source Failure to apply objective clinical analysis during nurse reception screening View source Failure to check pulse during resuscitation View source Insufficient airway ventilation assistance during resuscitation View source Failure to maintain clear resuscitation roles and responsibilities View source Ambiguity in reception screening questions for identifying increased-risk prisoners View source Failure to transfer person escort and forensic medical records to nurse reception screening View source See 12 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
Tedros Habtom KAHSSAY · 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
Tedros Kahssay killed himself by hanging in HM Prison Pentonville about a month after being admitted on a charge of murdering his pregnant partner. Concerns included incomplete transfer and recording of information, shortcomings in reception screening, and significantly deficient and chaotic resuscitation procedures. The report states that he was already dead when resuscitation commenced, while expressing concern for other prisoners requiring first aid.
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 Ineffective chest compressions during CPR
Wider context from the report “7. The resuscitation led by the two nurses occupying the positions of primary (Hotel 7) and secondary (Hotel 12) leads for emergency healthcare in the prison that night, was significantly lacking in the following ways.
• The nurse with primary responsibility for emergency care in the prison did not have a proper understanding of the nature of a code red and a code blue prison medical emergency. (I have raised this issue in the past.)
• One minute and twelve seconds elapsed after nurse arrival before any substantive care was given. The action during that one minute and twelve seconds did not appear to progress the resuscitation attempt.
• There seemed no clear demarcation of roles and responsibilities during the resuscitation. Of course these may change as those giving resuscitation tire, but the changes seemed haphazard.
• There was no checking for breath or airway manoeuvre at the outset or at any time during the resuscitation.
• There was no checking for pulse at the outset, before commencing chest compressions, or at any time during the resuscitation.
The lead nurse attempted to justify this by saying that she had not wanted to waste time. This was despite the first action upon finding the casualty being to apply a blood pressure cuff, on the basis that this was part of the nurse assessment.
• When giving evidence, the lead nurse appeared to conflate the casualty who is in cardiorespiratory arrest with the casualty who is merely unconscious. She repeatedly talked about the need to give cardiopulmonary resuscitation (CPR) to an unconscious casualty. She said that, at the time she started chest compressions, she did not know whether Mr Kahssay was breathing or not breathing.
• When CPR was given, chest compressions were ineffective, being too quick and too shallow .
• There was only one brief attempt to use an ambubag, the majority of the resuscitation taking place without airway assistance or with a non rebreathe oxygen mask.
• It appeared that one oxygen cylinder was empty, as it had to be changed for another.
The nurse leading the resuscitation described it as chaotic. That is indeed how it appeared to me from her description and from viewing the bodycam footage.
I was and remain very gravely concerned, not in this respect for Mr Kahssay who was in fact already dead when resuscitation commenced, but for anyone else in the prison in need of first aid.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 breathing and perform airway manoeuvres during resuscitation
Wider context from the report “7. The resuscitation led by the two nurses occupying the positions of primary (Hotel 7) and secondary (Hotel 12) leads for emergency healthcare in the prison that night, was significantly lacking in the following ways.
• The nurse with primary responsibility for emergency care in the prison did not have a proper understanding of the nature of a code red and a code blue prison medical emergency. (I have raised this issue in the past.)
• One minute and twelve seconds elapsed after nurse arrival before any substantive care was given. The action during that one minute and twelve seconds did not appear to progress the resuscitation attempt.
• There seemed no clear demarcation of roles and responsibilities during the resuscitation. Of course these may change as those giving resuscitation tire, but the changes seemed haphazard.
• There was no checking for breath or airway manoeuvre at the outset or at any time during the resuscitation .
• There was no checking for pulse at the outset, before commencing chest compressions, or at any time during the resuscitation.
The lead nurse attempted to justify this by saying that she had not wanted to waste time. This was despite the first action upon finding the casualty being to apply a blood pressure cuff, on the basis that this was part of the nurse assessment.
• When giving evidence, the lead nurse appeared to conflate the casualty who is in cardiorespiratory arrest with the casualty who is merely unconscious. She repeatedly talked about the need to give cardiopulmonary resuscitation (CPR) to an unconscious casualty. She said that, at the time she started chest compressions, she did not know whether Mr Kahssay was breathing or not breathing.
• When CPR was given, chest compressions were ineffective, being too quick and too shallow.
• There was only one brief attempt to use an ambubag, the majority of the resuscitation taking place without airway assistance or with a non rebreathe oxygen mask.
• It appeared that one oxygen cylinder was empty, as it had to be changed for another.
The nurse leading the resuscitation described it as chaotic. That is indeed how it appeared to me from her description and from viewing the bodycam footage.
I was and remain very gravely concerned, not in this respect for Mr Kahssay who was in fact already dead when resuscitation commenced, but for anyone else in the prison in need of first aid.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Unavailability of a serviceable oxygen cylinder during resuscitation
Wider context from the report “7. The resuscitation led by the two nurses occupying the positions of primary (Hotel 7) and secondary (Hotel 12) leads for emergency healthcare in the prison that night, was significantly lacking in the following ways.
• The nurse with primary responsibility for emergency care in the prison did not have a proper understanding of the nature of a code red and a code blue prison medical emergency. (I have raised this issue in the past.)
• One minute and twelve seconds elapsed after nurse arrival before any substantive care was given. The action during that one minute and twelve seconds did not appear to progress the resuscitation attempt.
• There seemed no clear demarcation of roles and responsibilities during the resuscitation. Of course these may change as those giving resuscitation tire, but the changes seemed haphazard.
• There was no checking for breath or airway manoeuvre at the outset or at any time during the resuscitation.
• There was no checking for pulse at the outset, before commencing chest compressions, or at any time during the resuscitation.
The lead nurse attempted to justify this by saying that she had not wanted to waste time. This was despite the first action upon finding the casualty being to apply a blood pressure cuff, on the basis that this was part of the nurse assessment.
• When giving evidence, the lead nurse appeared to conflate the casualty who is in cardiorespiratory arrest with the casualty who is merely unconscious. She repeatedly talked about the need to give cardiopulmonary resuscitation (CPR) to an unconscious casualty. She said that, at the time she started chest compressions, she did not know whether Mr Kahssay was breathing or not breathing.
• When CPR was given, chest compressions were ineffective, being too quick and too shallow.
• There was only one brief attempt to use an ambubag, the majority of the resuscitation taking place without airway assistance or with a non rebreathe oxygen mask.
• It appeared that one oxygen cylinder was empty , as it had to be changed for another .
The nurse leading the resuscitation described it as chaotic. That is indeed how it appeared to me from her description and from viewing the bodycam footage.
I was and remain very gravely concerned, not in this respect for Mr Kahssay who was in fact already dead when resuscitation commenced, but for anyone else in the prison in need of first aid.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure of emergency healthcare lead nurses to understand code red and code blue medical emergencies
Wider context from the report “7. The resuscitation led by the two nurses occupying the positions of primary (Hotel 7) and secondary (Hotel 12) leads for emergency healthcare in the prison that night, was significantly lacking in the following ways.
• The nurse with primary responsibility for emergency care in the prison did not have a proper understanding of the nature of a code red and a code blue prison medical emergency . (I have raised this issue in the past.)
• One minute and twelve seconds elapsed after nurse arrival before any substantive care was given. The action during that one minute and twelve seconds did not appear to progress the resuscitation attempt.
• There seemed no clear demarcation of roles and responsibilities during the resuscitation. Of course these may change as those giving resuscitation tire, but the changes seemed haphazard.
• There was no checking for breath or airway manoeuvre at the outset or at any time during the resuscitation.
• There was no checking for pulse at the outset, before commencing chest compressions, or at any time during the resuscitation.
The lead nurse attempted to justify this by saying that she had not wanted to waste time. This was despite the first action upon finding the casualty being to apply a blood pressure cuff, on the basis that this was part of the nurse assessment.
• When giving evidence, the lead nurse appeared to conflate the casualty who is in cardiorespiratory arrest with the casualty who is merely unconscious. She repeatedly talked about the need to give cardiopulmonary resuscitation (CPR) to an unconscious casualty. She said that, at the time she started chest compressions, she did not know whether Mr Kahssay was breathing or not breathing.
• When CPR was given, chest compressions were ineffective, being too quick and too shallow.
• There was only one brief attempt to use an ambubag, the majority of the resuscitation taking place without airway assistance or with a non rebreathe oxygen mask.
• It appeared that one oxygen cylinder was empty, as it had to be changed for another.
The nurse leading the resuscitation described it as chaotic. That is indeed how it appeared to me from her description and from viewing the bodycam footage.
I was and remain very gravely concerned, not in this respect for Mr Kahssay who was in fact already dead when resuscitation commenced, but for anyone else in the prison in need of first aid.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 distinguish cardiorespiratory arrest from unconsciousness during emergency assessment
Wider context from the report “7. The resuscitation led by the two nurses occupying the positions of primary (Hotel 7) and secondary (Hotel 12) leads for emergency healthcare in the prison that night, was significantly lacking in the following ways.
• The nurse with primary responsibility for emergency care in the prison did not have a proper understanding of the nature of a code red and a code blue prison medical emergency. (I have raised this issue in the past.)
• One minute and twelve seconds elapsed after nurse arrival before any substantive care was given. The action during that one minute and twelve seconds did not appear to progress the resuscitation attempt.
• There seemed no clear demarcation of roles and responsibilities during the resuscitation. Of course these may change as those giving resuscitation tire, but the changes seemed haphazard.
• There was no checking for breath or airway manoeuvre at the outset or at any time during the resuscitation.
• There was no checking for pulse at the outset, before commencing chest compressions, or at any time during the resuscitation.
The lead nurse attempted to justify this by saying that she had not wanted to waste time. This was despite the first action upon finding the casualty being to apply a blood pressure cuff, on the basis that this was part of the nurse assessment.
• When giving evidence, the lead nurse appeared to conflate the casualty who is in cardiorespiratory arrest with the casualty who is merely unconscious . She repeatedly talked about the need to give cardiopulmonary resuscitation (CPR) to an unconscious casualty. She said that, at the time she started chest compressions, she did not know whether Mr Kahssay was breathing or not breathing .
• When CPR was given, chest compressions were ineffective, being too quick and too shallow.
• There was only one brief attempt to use an ambubag, the majority of the resuscitation taking place without airway assistance or with a non rebreathe oxygen mask.
• It appeared that one oxygen cylinder was empty, as it had to be changed for another.
The nurse leading the resuscitation described it as chaotic. That is indeed how it appeared to me from her description and from viewing the bodycam footage.
I was and remain very gravely concerned, not in this respect for Mr Kahssay who was in fact already dead when resuscitation commenced, but for anyone else in the prison in need of first aid.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Delay in providing substantive resuscitation care after nurse arrival
Wider context from the report “7. The resuscitation led by the two nurses occupying the positions of primary (Hotel 7) and secondary (Hotel 12) leads for emergency healthcare in the prison that night, was significantly lacking in the following ways.
• The nurse with primary responsibility for emergency care in the prison did not have a proper understanding of the nature of a code red and a code blue prison medical emergency. (I have raised this issue in the past.)
• One minute and twelve seconds elapsed after nurse arrival before any substantive care was given . The action during that one minute and twelve seconds did not appear to progress the resuscitation attempt .
• There seemed no clear demarcation of roles and responsibilities during the resuscitation. Of course these may change as those giving resuscitation tire, but the changes seemed haphazard.
• There was no checking for breath or airway manoeuvre at the outset or at any time during the resuscitation.
• There was no checking for pulse at the outset, before commencing chest compressions, or at any time during the resuscitation.
The lead nurse attempted to justify this by saying that she had not wanted to waste time. This was despite the first action upon finding the casualty being to apply a blood pressure cuff, on the basis that this was part of the nurse assessment.
• When giving evidence, the lead nurse appeared to conflate the casualty who is in cardiorespiratory arrest with the casualty who is merely unconscious. She repeatedly talked about the need to give cardiopulmonary resuscitation (CPR) to an unconscious casualty. She said that, at the time she started chest compressions, she did not know whether Mr Kahssay was breathing or not breathing.
• When CPR was given, chest compressions were ineffective, being too quick and too shallow.
• There was only one brief attempt to use an ambubag, the majority of the resuscitation taking place without airway assistance or with a non rebreathe oxygen mask.
• It appeared that one oxygen cylinder was empty, as it had to be changed for another.
The nurse leading the resuscitation described it as chaotic. That is indeed how it appeared to me from her description and from viewing the bodycam footage.
I was and remain very gravely concerned, not in this respect for Mr Kahssay who was in fact already dead when resuscitation commenced, but for anyone else in the prison in need of first aid.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 explore recorded history of depression during reception screening
Wider context from the report “6. The second reception (well man) screening nurse did not explore the history of depression recorded , he said because the prison general practitioner had not prescribed any medication for depression. On reflection, the nurse thought that he should have asked about it.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to record circumstances of the index offence in the healthcare record
Wider context from the report “2. The index offence is recorded on the PER (and inputted onto the prison computer system NOMIS, though not the healthcare computer system SystmOne ), but not the circumstances . The circumstances – perhaps from the indictment read out in court – may be potentially helpful to healthcare and possibly also to discipline staff in prison.
This is not clear cut, because the logistics of obtaining the information and making it available to those who need it are complex; prosecutions must not be compromised; and there is the potential for making a prisoner’s mental state worse by probing the circumstances.
However, it seems that this is an issue that is worthy of consideration, preferably at a national level.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 general practitioner records
Wider context from the report “3. The general practitioner records were never obtained (an issue that I have raised in the past), despite there being a system in place for Pentonville healthcare administrative staff to do this. Whilst that did not impact upon Mr Kahssay’s care, it might for another prisoner.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to apply objective clinical analysis during nurse reception screening
Wider context from the report “5. Both nurses conducting reception screening talked often in evidence about not being able to do anything other than accept the answers given by the prisoner. They did not seem to bring any objective analysis to the screening . The process of nurse screening appeared at times to be a tick box exercise .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 check pulse during resuscitation
Wider context from the report “7. The resuscitation led by the two nurses occupying the positions of primary (Hotel 7) and secondary (Hotel 12) leads for emergency healthcare in the prison that night, was significantly lacking in the following ways.
• The nurse with primary responsibility for emergency care in the prison did not have a proper understanding of the nature of a code red and a code blue prison medical emergency. (I have raised this issue in the past.)
• One minute and twelve seconds elapsed after nurse arrival before any substantive care was given. The action during that one minute and twelve seconds did not appear to progress the resuscitation attempt.
• There seemed no clear demarcation of roles and responsibilities during the resuscitation. Of course these may change as those giving resuscitation tire, but the changes seemed haphazard.
• There was no checking for breath or airway manoeuvre at the outset or at any time during the resuscitation.
• There was no checking for pulse at the outset, before commencing chest compressions, or at any time during the resuscitation .
The lead nurse attempted to justify this by saying that she had not wanted to waste time. This was despite the first action upon finding the casualty being to apply a blood pressure cuff, on the basis that this was part of the nurse assessment.
• When giving evidence, the lead nurse appeared to conflate the casualty who is in cardiorespiratory arrest with the casualty who is merely unconscious. She repeatedly talked about the need to give cardiopulmonary resuscitation (CPR) to an unconscious casualty. She said that, at the time she started chest compressions, she did not know whether Mr Kahssay was breathing or not breathing.
• When CPR was given, chest compressions were ineffective, being too quick and too shallow.
• There was only one brief attempt to use an ambubag, the majority of the resuscitation taking place without airway assistance or with a non rebreathe oxygen mask.
• It appeared that one oxygen cylinder was empty, as it had to be changed for another.
The nurse leading the resuscitation described it as chaotic. That is indeed how it appeared to me from her description and from viewing the bodycam footage.
I was and remain very gravely concerned, not in this respect for Mr Kahssay who was in fact already dead when resuscitation commenced, but for anyone else in the prison in need of first aid.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 airway ventilation assistance during resuscitation
Wider context from the report “7. The resuscitation led by the two nurses occupying the positions of primary (Hotel 7) and secondary (Hotel 12) leads for emergency healthcare in the prison that night, was significantly lacking in the following ways.
• The nurse with primary responsibility for emergency care in the prison did not have a proper understanding of the nature of a code red and a code blue prison medical emergency. (I have raised this issue in the past.)
• One minute and twelve seconds elapsed after nurse arrival before any substantive care was given. The action during that one minute and twelve seconds did not appear to progress the resuscitation attempt.
• There seemed no clear demarcation of roles and responsibilities during the resuscitation. Of course these may change as those giving resuscitation tire, but the changes seemed haphazard.
• There was no checking for breath or airway manoeuvre at the outset or at any time during the resuscitation.
• There was no checking for pulse at the outset, before commencing chest compressions, or at any time during the resuscitation.
The lead nurse attempted to justify this by saying that she had not wanted to waste time. This was despite the first action upon finding the casualty being to apply a blood pressure cuff, on the basis that this was part of the nurse assessment.
• When giving evidence, the lead nurse appeared to conflate the casualty who is in cardiorespiratory arrest with the casualty who is merely unconscious. She repeatedly talked about the need to give cardiopulmonary resuscitation (CPR) to an unconscious casualty. She said that, at the time she started chest compressions, she did not know whether Mr Kahssay was breathing or not breathing.
• When CPR was given, chest compressions were ineffective, being too quick and too shallow.
• There was only one brief attempt to use an ambubag , the majority of the resuscitation taking place without airway assistance or with a non rebreathe oxygen mask .
• It appeared that one oxygen cylinder was empty, as it had to be changed for another.
The nurse leading the resuscitation described it as chaotic. That is indeed how it appeared to me from her description and from viewing the bodycam footage.
I was and remain very gravely concerned, not in this respect for Mr Kahssay who was in fact already dead when resuscitation commenced, but for anyone else in the prison in need of first aid.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 clear resuscitation roles and responsibilities
Wider context from the report “7. The resuscitation led by the two nurses occupying the positions of primary (Hotel 7) and secondary (Hotel 12) leads for emergency healthcare in the prison that night, was significantly lacking in the following ways.
• The nurse with primary responsibility for emergency care in the prison did not have a proper understanding of the nature of a code red and a code blue prison medical emergency. (I have raised this issue in the past.)
• One minute and twelve seconds elapsed after nurse arrival before any substantive care was given. The action during that one minute and twelve seconds did not appear to progress the resuscitation attempt.
• There seemed no clear demarcation of roles and responsibilities during the resuscitation . Of course these may change as those giving resuscitation tire, but the changes seemed haphazard .
• There was no checking for breath or airway manoeuvre at the outset or at any time during the resuscitation.
• There was no checking for pulse at the outset, before commencing chest compressions, or at any time during the resuscitation.
The lead nurse attempted to justify this by saying that she had not wanted to waste time. This was despite the first action upon finding the casualty being to apply a blood pressure cuff, on the basis that this was part of the nurse assessment.
• When giving evidence, the lead nurse appeared to conflate the casualty who is in cardiorespiratory arrest with the casualty who is merely unconscious. She repeatedly talked about the need to give cardiopulmonary resuscitation (CPR) to an unconscious casualty. She said that, at the time she started chest compressions, she did not know whether Mr Kahssay was breathing or not breathing.
• When CPR was given, chest compressions were ineffective, being too quick and too shallow.
• There was only one brief attempt to use an ambubag, the majority of the resuscitation taking place without airway assistance or with a non rebreathe oxygen mask.
• It appeared that one oxygen cylinder was empty, as it had to be changed for another.
The nurse leading the resuscitation described it as chaotic. That is indeed how it appeared to me from her description and from viewing the bodycam footage.
I was and remain very gravely concerned, not in this respect for Mr Kahssay who was in fact already dead when resuscitation commenced, but for anyone else in the prison in need of first aid.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Ambiguity in reception screening questions for identifying increased-risk prisoners
Wider context from the report “4. The first reception screen template contained questions that carried an inherent ambiguity , in that they related to a change in personal and family circumstances, which must always be the case when a person is incarcerated and therefore does not assist in determining which prisoners are at an increased 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 transfer person escort and forensic medical records to nurse reception screening
Wider context from the report “1. The person escort record (PER) and appended report of the forensic medical examiner (FME) that accompanied Mr Kahssay to HMP Pentonville did not accompany him to nurse reception screening .
” Open source report
Concerns raised 1 Lack of clarity in safer custody guidance 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
Roy Patrick Hoey · 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
Roy Patrick Hoey died by hanging using a curtain as a ligature while detained at HMP Altcourse on 4 September 2014. The report identified confusion among witnesses about the interpretation and application of safer custody and ACCT guidance, with potential implications for how risks of suicide or self-harm were assessed and managed 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 Lack of clarity in safer custody guidance
Wider context from the report “I am reporting this matter to NOMS as there was confusion for the witnesses when different parts of the guidance were put to them and this may lead to confusion as to what is required to apply the best practices of safer custody within prisons . It may be that clarification of the updated policy will improve safer custody, notwithstanding what the court was advised about the national training. Clarification would have certainly reduced the length of time for the inquest hearing considerably.
” 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 Revise PSI 64/2011 to resolve confusion about when staff should open an ACCT.
Verbatim wording from the response “NOMS acknowledges the potential for confusion regarding the opening of an ACCT, and this will be resolved in the revision of PSI 64/2011 due for completion by the end of April 2017.” Source location 2016-0360-Response-by-NOMS
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 An ACCT need not be opened automatically whenever risk is indicated; staff should communicate concerns, consider opening one, and record the decision.
Verbatim wording from the response “It is not the intention of the policy to require staff to open an ACCT automatically in every circumstance where a risk may be indicated but it is expected that they communicate their concerns immediately to the Residential Daily or Night Operational Manager, consider opening an ACCT plan and make a record of their decision in an appropriate source, for example the observation book and PNOMIS.” Source location 2016-0360-Response-by-NOMS
Open published response
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations