Concerns raised 2 Insufficient operational prison staffing for safe custody and officer safety View source Failure to account for prisoner type when determining safe staffing levels 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
Calam Atour · 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
Calam Atour died by suicide in his room at Erlestoke House on 13 May 2015, after hanging himself by a ligature from the window. The inquest identified concerns about staffing shortages, medical support and coordination, the ACCT process, and the adequacy of monitoring and responses to suicide risk. The report also raised concerns that staffing levels and the way staffing requirements were assessed could create unsafe conditions for prisoners and 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 Insufficient operational prison staffing for safe custody and officer safety
Wider context from the report “I. I am concerned that unless the staffing number issue is resolved that when Alfred & Wessex Units reopen next year it will again create a significant staffing issues and a reduction of around 20% in operational personnel . I am concerned that this level of reduction has the potential and propensity to create an unsafe system of work for the prison officers (I heard during the course of the Inquest that 1 officer who was due to attend Court to give evidence sadly was the victim of a serious assault whilst on duty at Erlestoke recently). I am concerned that with a reduction in operational staff members that there is a risk that such assaults will increase . Such assaults can result in serious injury or even worse death. I am also concerned as regards the welfare of the prisoners and as regards the ability of the prison officers as a result of the pressure on their numbers to safeguard the lives of those in prison insofar as reasonable practicable against the risk of prisoners harming themselves or others or even taking their own lives . It was clear that there was a huge amount of reliance of goodwill amongst prison staff but with the continuing pressure on staffing the reality I heard is that the goodwill gets eroded overtime, as the ability to function in the workplace becomes increasingly pressurised and more stressful . The position is not sustainable long term.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 account for prisoner type when determining safe staffing levels
Wider context from the report “III. It was also brought to my attention that in terms of benchmarking on the previous occasion, that it did not take into account the type of prisoners that may be sent to a particular prison . Insofar as Erlestoke is concerned, due to its rehabilitation categorisation and as regards the training and courses made available to prisoners that a considerable number of the prisoners at Erlestoke are either “lifers” or on an indeterminate prison sentence , both of these, of course, relate to serious crimes. I am concerned that not taking into account the type of prisoner when determining safe/efficient numbers of personnel could lead to a lower than safe number of personnel available for duty . This concerns overlaps and dovetails with my concern at para I. above.
” Open source report
Concerns raised 2 Failure to investigate dismissal processes for errors and lessons learned View source Limited management support during disciplinary investigations 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
Andrew David Machin · 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 David Machin died by hanging from a tree in Pailton Pastures shortly after being informed of the Prison Service’s decision to dismiss him after 18 years of service. His body was discovered by police on 10 May 2016. The report raised concerns about limited support from prison management during the disciplinary investigation and the absence of an internal investigation into the dismissal process after his death.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to investigate dismissal processes for errors and lessons learned
Wider context from the report “(2) Notwithstanding the fact that Mr Machin’s death occurred in such close proximity in time to his disciplinary hearing and subsequent dismissal, there had been no internal investigation into the circumstances of that dismissal process to identify whether there had been any errors made or any lessons to be learned from it . This seemed all the more surprising in view of the fact that I was informed at the Inquest that although summarily dismissed, Mr Machin would have still been considered to be an employee until the time of any appeal of that dismissal had elapsed
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Limited management support during disciplinary investigations
Wider context from the report “(1)Mr Machin appeared to have had limited support from prison management during the disciplinary investigation process , despite the fact that this process continued for nearly 5 months prior to his disciplinary hearing on 9 May 2016 and he was suspended from his employment throughout this time.
” Open source report
Concerns raised 6 Premature closure of ACCTs before identified inadequacies are detected and needs are properly served View source Failure of the ACCT document to accompany prisoners around the prison View source Failure to read and use available documentary information in ACCT reviews View source Insufficient resourcing for officers’ duties to keep prisoners safe from self-harm View source Failure to complete ACCT documentation fully View source Failure to invite all appropriate individuals to ACCT reviews View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Liam Adrian John Lambert · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Liam Adrian John Lambert was a young offender at Glen Parva Young Offenders Institution who died after ligaturing himself in a single cell on the evening of 19 March 2015. The report identified concerns about bullying and assaults, inadequate completion and use of the ACCT self-harm documentation, its inappropriate closure, prison resourcing, and delays in the emergency response and access for paramedics.
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 Premature closure of ACCTs before identified inadequacies are detected and needs are properly served
Wider context from the report “2. This ACCT was only open for a short period. It did not serve Liam’s needs properly and was closed before any review system picked up the inadequacies.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure of the ACCT document to accompany prisoners around the prison
Wider context from the report “1. The ACCT document was not completed fully, did not accompany Liam around the prison as it should have and not all appropriate individuals were invited to the reviews. Available documentary information was not read or used, and pressures of time were cited to explain these failings. Consideration should be given to formally confirming that all necessary documentation has been considered prior to the ACCT review, and to ensure the Officers and Healthcare staff are aware of their 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 Failure to read and use available documentary information in ACCT reviews
Wider context from the report “1. The ACCT document was not completed fully, did not accompany Liam around the prison as it should have and not all appropriate individuals were invited to the reviews. Available documentary information was not read or used , and pressures of time were cited to explain these failings. Consideration should be given to formally confirming that all necessary documentation has been considered prior to the ACCT review, and to ensure the Officers and Healthcare staff are aware of their 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 Insufficient resourcing for officers’ duties to keep prisoners safe from self-harm
Wider context from the report “3. The Governor provided evidence that resourcing was affecting the ability of officers to carry out their duties regarding keeping prisoners safe from self harm . In this particularly vulnerable population of young men, their safety is paramount and this should be the first consideration.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 ACCT documentation fully
Wider context from the report “1. The ACCT document was not completed fully , did not accompany Liam around the prison as it should have and not all appropriate individuals were invited to the reviews. Available documentary information was not read or used, and pressures of time were cited to explain these failings. Consideration should be given to formally confirming that all necessary documentation has been considered prior to the ACCT review, and to ensure the Officers and Healthcare staff are aware of their 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 Failure to invite all appropriate individuals to ACCT reviews
Wider context from the report “1. The ACCT document was not completed fully, did not accompany Liam around the prison as it should have and not all appropriate individuals were invited to the reviews . Available documentary information was not read or used, and pressures of time were cited to explain these failings. Consideration should be given to formally confirming that all necessary documentation has been considered prior to the ACCT review, and to ensure the Officers and Healthcare staff are aware of their responsibilities.
” Open source report
Concerns raised 4 Failure to communicate less obvious suicide and self-harm risk factors View source Lack of meaningful pastoral interaction with a dedicated custodial officer View source Failure to comprehensively record suicide and self-harm risk observations View source Failure to identify less obvious suicide and self-harm risk factors at initial screening 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
Peter 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
Peter Lawrence was remanded into custody at HMP Peterborough and, on 02.02.15, was found in a prison workshop toilet cubicle having stabbed himself with a chisel; he was taken to hospital where death was confirmed. The concerns related to identifying and recording suicide or self-harm risks during the initial screening of first-time prisoners, and to the absence of meaningful interaction with a custodial officer who could help identify and manage such risks.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate less obvious suicide and self-harm risk factors
Wider context from the report “(1) The inquest heard a great deal of evidence relating to the process for identifying, managing and recording risk at the first point of contact between new prisoners and prison/healthcare staff. Mr Lawrence had not been in prison before and there was very little background information available to enable staff to identify less obvious risk factors, particularly in relation to the nature of the alleged offences. It was accepted in evidence that it was of particular importance at the initial screening to identify risk by other means and to record any observations in a comprehensive manner for future reference. HMP Peterborough has put in place a number of measures in recognition of the concern that suicide/self harm risk is identified at the earliest stage, even if no ACCT document is opened. The concern that risk factors may be missed or inadequately recorded has been addressed locally but there may be scope to expand awareness that individuals entering prison for the first time may be accompanied by only limited information. The situation is worsened where there is limited information available about the nature of the alleged offending. The identification and communication of less obvious risk factors is crucial ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 meaningful pastoral interaction with a dedicated custodial officer
Wider context from the report “(2) The use of personal (or ‘custodial’) officers was identified as an important aspect of risk management. The jury identified the absence of interaction with a custodial officer in the current case to have been a missed opportunity to further identify and consider the risk of suicide/self harm. Again this has been addressed locally. The lack of meaningful interaction with a dedicated member of staff in a pastoral capacity , particularly for those in prison for the first time , gives rise to a concern that deaths may occur in other cases nationally.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to comprehensively record suicide and self-harm risk observations
Wider context from the report “(1) The inquest heard a great deal of evidence relating to the process for identifying, managing and recording risk at the first point of contact between new prisoners and prison/healthcare staff. Mr Lawrence had not been in prison before and there was very little background information available to enable staff to identify less obvious risk factors, particularly in relation to the nature of the alleged offences. It was accepted in evidence that it was of particular importance at the initial screening to identify risk by other means and to record any observations in a comprehensive manner for future reference . HMP Peterborough has put in place a number of measures in recognition of the concern that suicide/self harm risk is identified at the earliest stage, even if no ACCT document is opened. The concern that risk factors may be missed or inadequately recorded has been addressed locally but there may be scope to expand awareness that individuals entering prison for the first time may be accompanied by only limited information. The situation is worsened where there is limited information available about the nature of the alleged offending. The identification and communication of less obvious risk factors is crucial;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 less obvious suicide and self-harm risk factors at initial screening
Wider context from the report “(1) The inquest heard a great deal of evidence relating to the process for identifying, managing and recording risk at the first point of contact between new prisoners and prison/healthcare staff. Mr Lawrence had not been in prison before and there was very little background information available to enable staff to identify less obvious risk factors , particularly in relation to the nature of the alleged offences. It was accepted in evidence that it was of particular importance at the initial screening to identify risk by other means and to record any observations in a comprehensive manner for future reference. HMP Peterborough has put in place a number of measures in recognition of the concern that suicide/self harm risk is identified at the earliest stage, even if no ACCT document is opened. The concern that risk factors may be missed or inadequately recorded has been addressed locally but there may be scope to expand awareness that individuals entering prison for the first time may be accompanied by only limited information. The situation is worsened where there is limited information available about the nature of the alleged offending. The identification and communication of less obvious risk factors is crucial;
” Open source report
Concerns raised 3 Failure of suicide risk guidance to include irrational behaviour indicative of psychosis View source Failure to open an ACCT document when behaviour indicates a need for additional monitoring View source Lack of descriptions of symptoms of undiagnosed mental illness in suicide risk guidance 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
Stephen St Clair · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Stephen St Clair, a prisoner at HMP Isle of Wight, was found in his cell on 4 November 2013 with a severe cut to his throat and was pronounced dead at 05.55 hours. The report describes concerns about signs of paranoia and possible psychosis not being recognised as suicide or self-harm risk, and about the absence of corresponding wording in the Prison Service suicide risk guidance, which may have contributed to an ACCT not being opened.
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 suicide risk guidance to include irrational behaviour indicative of psychosis
Wider context from the report “2. The next section in PSI 64/2011 deals with “Risk Factors for Self-Harm” and includes a sub-heading entitled “Current Context” where the following is included: “Irrational behaviour, out of touch with reality”.
3. I am concerned that the “Risk Factors for Suicide” does not actually include words to the effect of “Irrational behaviour, out of touch with reality” as the evidence from the Consultant Forensic Psychiatrist suggested that this behaviour was strongly suggestive of psychosis , and as such, the prisoner was in need of additional monitoring to keep him safe and to protect him from self-harm or suicide.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to open an ACCT document when behaviour indicates a need for additional monitoring
Wider context from the report “4. I am concerned that as this additional wording was not included in PSI 64/2011, the Prison Officers did not feel obligated to open an ACCT document , which may have resulted in Mr St Clair being monitored more closely, thereby avoiding him taking his own life.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 descriptions of symptoms of undiagnosed mental illness in suicide risk guidance
Wider context from the report “1. The Prison Service Instruction (“PSI”) 64/2011 (Management of prisoners at risk of harm to self, to others and from others (Safer Custody)) addresses the “Risk Factors for Suicide”. There are various subheadings, including “Clinical History” where the following point is made: “Mental illness diagnosis (e.g. depression, bipolar disorder, schizophrenia)” but there is no description of the possible symptoms which might be displayed by those who may be suffering from as yet undiagnosed conditions .
” Open source report
Concerns raised 2 Lack of sufficient ACCT training among staff View source Failure to adhere to mandatory ACCT process provisions 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 Brandon Betteridge · 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 Brandon Betteridge was remanded to HMP Durham on 22 May 2015 and was found dead in his cell on 26 May 2015 after hanging himself. Concerns included gaps in staff training and failures to follow mandatory ACCT procedures, including the closure of the ACCT without healthcare staff present. The inquest found that the absence of his prescription medication and the fact that he was not on an open ACCT probably contributed more than minimally to his death.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Lack of sufficient ACCT training among staff
Wider context from the report “(1) A member of the Healthcare staff indicated that at the time of the death, though she was working in the prison, she had not received any ACCT training. I was told that ACCT training is now part of Healthcare staff induction training. A prison GP with 11 years’ experience of working in prisons stated that he had never received ACCT training though he had opened ACCTs. A Senior Officer who chaired the first review of the ACCT at which the ACCT was closed) believed it was good practice but did not know it was mandatory that healthcare staff should be present at such a review. The inquest has shown that notwithstanding that the ACCT process has been in existence for a number of years, some staff were working without having received any training and some either not had sufficient training or had forgotten it or were not applying it with the result that mandatory provisions in the ACCT process were not being adhered to. The inquest has indicated a clear training need.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to adhere to mandatory ACCT process provisions
Wider context from the report “(1) A member of the Healthcare staff indicated that at the time of the death, though she was working in the prison, she had not received any ACCT training. I was told that ACCT training is now part of Healthcare staff induction training. A prison GP with 11 years’ experience of working in prisons stated that he had never received ACCT training though he had opened ACCTs. A Senior Officer who chaired the first review of the ACCT at which the ACCT was closed) believed it was good practice but did not know it was mandatory that healthcare staff should be present at such a review. The inquest has shown that notwithstanding that the ACCT process has been in existence for a number of years, some staff were working without having received any training and some either not had sufficient training or had forgotten it or were not applying it with the result that mandatory provisions in the ACCT process were not being adhered to . The inquest has indicated a clear training need.
” Open source report
Concerns raised 16 Failure to refer antidepressant history to a prison GP View source Failure to enter collateral history into the main clinical records View source Failure to record assessment of mood and suicidal thoughts during prison triage View source Failure to assess drug use during prison triage View source Failure to consider continuation of prescribed citalopram View source Failure to record consideration or a management plan for depression View source Delay in providing the ambulance with the prison gate location View source Inconsistent understanding of prison healthcare emergency procedures View source Out-of-date intermediate life support certification View source Delay in emergency nurse attendance at the patient’s side View source Failure to record discussion or a management plan for schizophrenia View source Failure to recognise prior compliant antidepressant treatment View source Restricted immediate access to the emergency defibrillator View source Failure to promptly acknowledge emergency radio calls View source Lack of current mandatory basic life support and first aid training for all prison officers View source Failure to re-check the pulse during resuscitation View source See 13 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
Samuel Rodney Darren BLAIR · 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
Rodney Blair, who had a history of paranoid schizophrenia, alcohol dependency, multiple drug use and depression, was remanded in custody at HM Prison Pentonville and was found hanging in his cell on 2 August 2015. The inquest concluded that his death was suicide, with several contributing factors. Concerns included gaps in assessment and management of his mental health and antidepressant treatment, and delays and procedural issues in the prison emergency response.
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 refer antidepressant history to a prison GP
Wider context from the report “4. There is no record from that meeting or any other time, of any consideration of or management plan for Mr Blair’s depression.
Most particularly, there is no record that it was ever recognised by the healthcare staff at HMP Pentonville that Mr Blair had been prescribed and had been compliant with the prescription of an anti depressant before his incarceration.
The assistant psychologist who obtained the history of a prescription of anti depressant medication did not refer Mr Blair to a prison GP for consideration of this .
Mr Blair was never offered any continuation of his citalopram prescription. The plan in the community had been to continue the prescription, but there is no record that this was ever considered by healthcare staff at HMP Pentonville.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 enter collateral history into the main clinical records
Wider context from the report “2. She later uploaded to the computer system the collateral history she had been sent as a Word document, but did not input any of it into the main body of the records , nor did the psychiatrist who made the note at the multi disciplinary team meeting in prison on 7 July 2015 at which Mr Blair was discussed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 assessment of mood and suicidal thoughts during prison triage
Wider context from the report “1. Although the assistant psychologist who triaged Mr Blair in prison on 2 July 2015 asked him about his alcohol dependency, she did not ask him about drug use, nor did she record asking him about his mood or any suicidal thoughts.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 drug use during prison triage
Wider context from the report “1. Although the assistant psychologist who triaged Mr Blair in prison on 2 July 2015 asked him about his alcohol dependency, she did not ask him about drug use , nor did she record asking him about his mood or any suicidal thoughts.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 continuation of prescribed citalopram
Wider context from the report “4. There is no record from that meeting or any other time, of any consideration of or management plan for Mr Blair’s depression.
Most particularly, there is no record that it was ever recognised by the healthcare staff at HMP Pentonville that Mr Blair had been prescribed and had been compliant with the prescription of an anti depressant before his incarceration.
The assistant psychologist who obtained the history of a prescription of anti depressant medication did not refer Mr Blair to a prison GP for consideration of this.
Mr Blair was never offered any continuation of his citalopram prescription . The plan in the community had been to continue the prescription, but there is no record that this was ever considered by healthcare staff at HMP Pentonville .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 consideration or a management plan for depression
Wider context from the report “4. There is no record from that meeting or any other time, of any consideration of or management plan for Mr Blair’s depression .
Most particularly, there is no record that it was ever recognised by the healthcare staff at HMP Pentonville that Mr Blair had been prescribed and had been compliant with the prescription of an anti depressant before his incarceration.
The assistant psychologist who obtained the history of a prescription of anti depressant medication did not refer Mr Blair to a prison GP for consideration of this.
Mr Blair was never offered any continuation of his citalopram prescription. The plan in the community had been to continue the prescription, but there is no record that this was ever considered by healthcare staff at HMP Pentonville.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 the ambulance with the prison gate location
Wider context from the report “5. After Mr Blair was found hanging, the officer in the prison control room did not give the prison gate location for the ambulance at the very outset of the 999 call to London Ambulance Service, but instead did so part way through the call.
The LAS controller did not ask at the very outset.
The ideal would be for the information to be given at the very beginning of any emergency call .
(I wrote to HMP Pentonville on 16 September 2016 in connection with the death of another prisoner about this issue. I appreciate that work on this matter is ongoing.)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Inconsistent understanding of prison healthcare emergency procedures
Wider context from the report “9. That nurse gave a description of the code blue and code red system of describing an emergency, that was markedly different from the understanding given by the prison governor and the London Ambulance Service . I heard that the codes blue and red are even described on posters within the prison.
It therefore appears that a nurse within the prison healthcare team has the wrong understanding of basic prison healthcare emergency procedures .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Out-of-date intermediate life support certification
Wider context from the report “8. That nurse (a mental health, rather than general nurse) began resuscitation. He gave evidence that he started chest compressions and continued these for two minutes until a custodial manager arrived, without any intention of ever stopping to re-check Mr Blair’s pulse.
He said that, whilst his basic life support certification was current at the time of Mr Blair’s death, his intermediate life support certification was not, and is still not ; it is currently at least three years out of date .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 emergency nurse attendance at the patient’s side
Wider context from the report “6. The prison nurse on call for emergencies, call sign Hotel 7, who was called to attend Mr Blair after he had been found hanging, did not acknowledge the radio call for several minutes, despite numerous attempts by prison control.
When she finally did acknowledge the emergency, there was a delay of up to approximately 15 minutes before she was at Mr Blair’s side .
(I wrote to HMP Pentonville on 16 September 2016 in connection with the death of another prisoner about a different nurse, but also in the role of Hotel 7, who did not respond to an emergency alarm as soon as it was activated.)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 discussion or a management plan for schizophrenia
Wider context from the report “3. There is no record from that meeting of any discussion or management plan for Mr Blair’s schizophrenia .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 prior compliant antidepressant treatment
Wider context from the report “4. There is no record from that meeting or any other time, of any consideration of or management plan for Mr Blair’s depression.
Most particularly, there is no record that it was ever recognised by the healthcare staff at HMP Pentonville that Mr Blair had been prescribed and had been compliant with the prescription of an anti depressant before his incarceration .
The assistant psychologist who obtained the history of a prescription of anti depressant medication did not refer Mr Blair to a prison GP for consideration of this.
Mr Blair was never offered any continuation of his citalopram prescription. The plan in the community had been to continue the prescription, but there is no record that this was ever considered by healthcare staff at HMP Pentonville.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Restricted immediate access to the emergency defibrillator
Wider context from the report “7. The substance misuse nurse in the detoxification wing did respond immediately. He took his emergency bag with him to Mr Blair’s cell, but did not take the defibrillator stored in the same room as the bag . He later had to leave Mr Blair to retrieve the defibrillator , because it is stored in the nurses’ room and only nurses have the key .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 promptly acknowledge emergency radio calls
Wider context from the report “6. The prison nurse on call for emergencies, call sign Hotel 7, who was called to attend Mr Blair after he had been found hanging, did not acknowledge the radio call for several minutes, despite numerous attempts by prison control .
When she finally did acknowledge the emergency, there was a delay of up to approximately 15 minutes before she was at Mr Blair’s side.
(I wrote to HMP Pentonville on 16 September 2016 in connection with the death of another prisoner about a different nurse, but also in the role of Hotel 7, who did not respond to an emergency alarm as soon as it was activated.)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 current mandatory basic life support and first aid training for all prison officers
Wider context from the report “The prison officers who found Mr Blair hanging did not have current basic life support training and so were not able to commence cardiopulmonary resuscitation (CPR) before the arrival of nurses . One officer tried to take Mr Blair’s pulse, but was unclear about the correct procedure for this .
This is a situation that I have noted before at HMP Pentonville. I have not made a prevention of future deaths report in the past, because I am aware that the fact that there is no mandatory first aid (including CPR) training for all prison officers is a nationally made, resource led decision.
However, it seems to me that you, as the decision maker regarding not providing such training, should be aware of the impact that this may have on the prison population.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 re-check the pulse during resuscitation
Wider context from the report “8. That nurse (a mental health, rather than general nurse) began resuscitation. He gave evidence that he started chest compressions and continued these for two minutes until a custodial manager arrived, without any intention of ever stopping to re-check Mr Blair’s pulse .
He said that, whilst his basic life support certification was current at the time of Mr Blair’s death, his intermediate life support certification was not, and is still not; it is currently at least three years out of date.
” Open source report
Concerns raised 6 Lack of proper provision for care and supervision of prisoners with complex physical and/or mental health needs View source Insufficient prison staffing for proper regimes and unlocking of prisoners requiring four person unlocks in the Segregation Unit View source Rife use of New Psychoactive Substances within the prison View source Insufficient staffing of the Substance Misuse Team View source Failure of healthcare staff to recognise urgent physical symptoms obscured by mental health issues View source Unclear or unavailable documentary tool for decisions about prisoners remaining in Segregation View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Shalan Blackwood · 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
Shalan Blackwood died at HMP Nottingham on 5 August 2015 as a result of bleeding from a duodenal ulcer. The report identified concerns about inadequate care and supervision for prisoners with complex physical or mental health needs, insufficient staffing for prisoners in segregation requiring a four-person unlock, unclear decision-making tools, widespread use of New Psychoactive Substances, and insufficient recognition of urgent physical symptoms obscured by mental health issues.
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 proper provision for care and supervision of prisoners with complex physical and/or mental health needs
Wider context from the report “1. That there is no proper provision for the care and supervision of prisoners who present with complex physical and/or mental health needs . It is understood that such a provision could be provided by means of an inpatient unit within the prison, such as for example is the case at HMP Liverpool.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Insufficient prison staffing for proper regimes and unlocking of prisoners requiring four person unlocks in the Segregation Unit
Wider context from the report “2. That at present, if a prisoner is assessed as needing a four person unlock, and is within the Segregation Unit, there are insufficient prison staff to provide him with a proper regime and to unlock him after lunchtime , for example to allow
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Rife use of New Psychoactive Substances within the prison
Wider context from the report “3. That the use of New Psychoactive Substances (NPS) remains rife within the prison , and presentations such as Mr Blackwood’s are not diminishing , and that the Substance Misuse Team requires further staff to be effective in future.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 of the Substance Misuse Team
Wider context from the report “3. That the use of New Psychoactive Substances (NPS) remains rife within the prison, and presentations such as Mr Blackwood’s are not diminishing, and that the Substance Misuse Team requires further staff to be effective in future .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 recognise urgent physical symptoms obscured by mental health issues
Wider context from the report “5. That healthcare staff are insufficiently alert to the issue that physical symptoms which require urgent medical attention may be occluded by mental health issues .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 or unavailable documentary tool for decisions about prisoners remaining in Segregation
Wider context from the report “4. That the documentary tool for decision making between prison staff and healthcare staff , as to whether a prisoner is fit to remain in Segregation and should do so , is unclear in or in use .
” Open source report
Concerns raised 10 Inadequate First Aid training for prison staff View source Selective emergency First Aid training among prison staff View source Lack of mental health experience and/or training among reception nursing staff View source Involvement of prison staff lacking relevant training or appropriate rank in the ACCT process View source Hesitancy to enter a cell during an emergency because of an instruction not to enter cells alone View source Failure to ensure medical professional attendance at First Care Reviews View source Failure of reception nursing staff to consult historical medical notes during reception interviews View source Limited accessibility of health and/or mental health care during weekends and Bank Holidays View source Reliance on verbal handovers rather than written records for prisoner information View source Failure to prepare sufficiently full ACCT assessment notes View source See 7 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Steven James May · 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
Steven James May died by hanging at HMP Ranby on 25 May 2015 at 01:45, after previously expressing suicidal intent and being placed on the ACCT programme. The report identified concerns about failures in reception health screening, ACCT documentation and reviews, information handovers, staff training and involvement, emergency first aid, cell-entry procedures, and access to health and mental health care.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Inadequate First Aid training for prison staff
Wider context from the report “(9) The inadequacy of First Aid training provided to prison staff in any event (namely, the administration of CPR by prison staff whilst the deceased was lying on a bed );
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Selective emergency First Aid training among prison staff
Wider context from the report “(7) The selective training of prison staff in emergency First Aid (namely the first member of prison staff on the scene of the death was not trained in the administration of CPR and was ignorant of the location of and method of use of defibrillators );
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 mental health experience and/or training among reception nursing staff
Wider context from the report “(2) The lack of experience and/or training of reception nursing staff in the field of mental health ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Involvement of prison staff lacking relevant training or appropriate rank in the ACCT process
Wider context from the report “(5) The involvement in the ACCT process of prison staff possessing neither relevant training nor the appropriate rank ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Hesitancy to enter a cell during an emergency because of an instruction not to enter cells alone
Wider context from the report “(8) The hesitancy of the first member of prison staff on the scene to enter the deceased’s cell in apparent adherence to an instruction not to enter cells alone ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 medical professional attendance at First Care Reviews
Wider context from the report “(6) The failure of prison staff to ensure the attendance of a medical professional at the First Care Review ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure of reception nursing staff to consult historical medical notes during reception interviews
Wider context from the report “(1) The failure of reception nursing staff , by reason of lack of training and/or instruction or lack of staff and/or time , to consult the deceased’s historical medical notes prior to or during the reception interview ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Limited accessibility of health and/or mental health care during weekends and Bank Holidays
Wider context from the report “(10) The accessibility of health and/or mental health care to inmates at weekends and during Bank Holidays .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Reliance on verbal handovers rather than written records for prisoner information
Wider context from the report “(4) Reliance by prison staff on verbal and/or oral handovers of information, rather than written records , regarding the deceased ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 prepare sufficiently full ACCT assessment notes
Wider context from the report “(3) The failure of prison staff when preparing the ACCT document to prepare as full a note as possible . For example, to follow the subject areas suggested in the narrative accompanying sections 1-8 of the Assessment Interview ;
” 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 prison and healthcare information-sharing procedures to ensure information is shared and recorded appropriately.
Verbatim wording from the response “At HMP Ranby a notice was issued in February 2016 reminding staff that those responsible for a prisoner on an open ACCT must record all relevant information in the ACCT document, the wing observation book and on the P-NOMIS system. Both the prison and the healthcare provider have recently reviewed their procedures to ensure that systems are in place for information to be shared between prison and healthcare staff and recorded appropriately. In order further to improve information sharing, meetings of the multi-disciplinary team for prisoners identified as being vulnerable or at risk of harm are held every two weeks, and any ongoing concerns are discussed and recorded.” Source location Steven-May-Response
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 staff information on defibrillator locations and use.
Verbatim wording from the response “The PSI becomes effective on 16 May 2016, and in preparation for its implementation, the Governor of HMP Ranby is reviewing the band/grade and numbers of staff who need to be trained in first aid. The prison currently has 61 staff trained in FAW and 73 in EFAW. 86 staff have received training in the use of defibrillators, and all staff have been provided with information on the location and use of defibrillators through a staff information notice issued on 16 July 2015.” Source location Steven-May-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reinforce Local Security Strategy procedures for responding to potentially life-threatening situations in cells.
Verbatim wording from the response “HMP Ranby has reinforced the relevant elements of its LSS, and issued a staff notice to this effect on 9 September 2015. All staff have been given access to the LSS and their knowledge of it will be tested annually.” Source location Steven-May-Response
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 improved operational guidance for ACCT processes.
Verbatim wording from the response “At national level a review of the ACCT process was conducted in 2015 and NOMS is taking forward work on the recommendations, including issuing improved operational guidance for staff, developing a shorter and clearer ACCT plan and improving the content and delivery of safer custody training.” Source location Steven-May-Response
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 notice requiring relevant information to be recorded in ACCT documents, wing observation books and P-NOMIS.
Verbatim wording from the response “At HMP Ranby a notice was issued in February 2016 reminding staff that those responsible for a prisoner on an open ACCT must record all relevant information in the ACCT document, the wing observation book and on the P-NOMIS system. Both the prison and the healthcare provider have recently reviewed their procedures to ensure that systems are in place for information to be shared between prison and healthcare staff and recorded appropriately. In order further to improve information sharing, meetings of the multi-disciplinary team for prisoners identified as being vulnerable or at risk of harm are held every two weeks, and any ongoing concerns are discussed and recorded.” Source location Steven-May-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Improve safer custody training content and delivery.
Verbatim wording from the response “At national level a review of the ACCT process was conducted in 2015 and NOMS is taking forward work on the recommendations, including issuing improved operational guidance for staff, developing a shorter and clearer ACCT plan and improving the content and delivery of safer custody training.” Source location Steven-May-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remind staff to make comprehensive records of ACCT assessment interviews.
Verbatim wording from the response “Staff at HMP Ranby were reminded of the need to make comprehensive records of all such interviews at a briefing on 23 March 2016. All ACCT documents at the prison are now being monitored by the Head of Safer Custody and the quality assurance check that is conducted addresses this point.” Source location Steven-May-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor ACCT documents through Head of Safer Custody oversight and quality assurance checks.
Verbatim wording from the response “Staff at HMP Ranby were reminded of the need to make comprehensive records of all such interviews at a briefing on 23 March 2016. All ACCT documents at the prison are now being monitored by the Head of Safer Custody and the quality assurance check that is conducted addresses this point.” Source location Steven-May-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Ensure first-aid training is delivered by competent, approved or currently certificated instructors.
Verbatim wording from the response “PSI 29/2015 is clear that all training provided to NOMS staff must be delivered by competent instructors, either by external providers from an approved list or trained and currently certificated NOMS trainers.” Source location Steven-May-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remind ACCT case managers that initial case reviews must include healthcare staff.
Verbatim wording from the response “All case managers at HMP Ranby have been reminded that the initial case review must be attended by a member of healthcare staff, and the healthcare provider has adjusted its delivery model to make this possible.” Source location Steven-May-Response
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 bands, grades and numbers of staff requiring first-aid training.
Verbatim wording from the response “The PSI becomes effective on 16 May 2016, and in preparation for its implementation, the Governor of HMP Ranby is reviewing the band/grade and numbers of staff who need to be trained in first aid. The prison currently has 61 staff trained in FAW and 73 in EFAW. 86 staff have received training in the use of defibrillators, and all staff have been provided with information on the location and use of defibrillators through a staff information notice issued on 16 July 2015.” Source location Steven-May-Response
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 Clarify band and grade requirements for ACCT assessor and case manager roles.
Verbatim wording from the response “One of the recommendations of the national review of the ACCT process referred to above was for further work to clarify the band/grade requirements for staff in assessor and case manager roles and work on this is being taken forward during 2016.” Source location Steven-May-Response
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 Test all staff annually on their knowledge of the Local Security Strategy.
Verbatim wording from the response “HMP Ranby has reinforced the relevant elements of its LSS, and issued a staff notice to this effect on 9 September 2015. All staff have been given access to the LSS and their knowledge of it will be tested annually.” Source location Steven-May-Response
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Healthcare concerns are assigned to NHS England and Nottinghamshire Healthcare NHS Foundation Trust, which addressed them separately.
Verbatim wording from the response “You will be aware that healthcare at HMP Ranby is commissioned by NHS England and provided by Nottinghamshire Healthcare NHS Foundation Trust, and I understand that the matters of concern that you have raised at points 1, 2 and 10 have been addressed separately by the Chief Executive of the Trust in a letter dated 13 April 2016, and by the Clinical Quality Manager at NHS England in a letter dated 5 May 2016. This response therefore addresses the matters of concern at points 3 to 9.” Source location Steven-May-Response
Open published response
Concerns raised 7 Lack of social worker knowledge of Transition Plans View source Failure to ensure YOT and YJB knowledge and expertise are considered in placements before completion of the Transition Plan View source Lack of accessible universal records throughout the offender pathway View source Disconnection between Looked After Child pathway planning and Transition Planning View source Failure to propose clinical interventions View source Failure to record clinical history and examination View source Failure of social workers to communicate directly with secure estate staff 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
Imran DOUGLAS · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Imran Douglas died by suicide on 13 November 2013, on the fifth day of his detention at HMP Belmarsh, after being sentenced to 18 years. The report identified concerns about transition and placement arrangements, communication and information-sharing between agencies, access to electronic records, and the adequacy of a medical assessment and response to suicide risk.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Lack of social worker knowledge of Transition Plans
Wider context from the report “Evidence pointed to a disconnection between Looked After Child pathway planning and Transition Planning. A social worker said that the LAC plan was “potentially informative” but did not matter if it was not completed, but that now it is regarded as key and should be shared. One social worker said she did not know what a Transition Plan was . The current Head of Children's Social Care at LB Tower Hamlets said that staff pressures at the time had eased somewhat, but that under her leadership the interface with the secure estate was through the YJB and so social workers do not directly talk to the secure estate staff. This was despite the requirement for the two to work together in the Youth to Adult Transitions Framework. Given the lack of documented communications of the risks and concerns between YOT and Feltham in 2013, this evidence throws doubt on the reported improvements in training and changes in interagency communication have been put into operation since.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 YOT and YJB knowledge and expertise are considered in placements before completion of the Transition Plan
Wider context from the report “I consider that there is an outstanding risk that, when a rising 18 enters the criminal justice system with insufficient time for the normal Transition Plan, and especially when staff are under pressure, that even with the changes in placements from courts that have been made, and the Joint National Protocol, the knowledge and expertise of the YOT and YJB may not be properly considered in a placement if the legal duty for placement has passed to the PMU before the Plan is complete .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Lack of accessible universal records throughout the offender pathway
Wider context from the report “The jury criticised the lack of access of HMP Belmarsh to the E Asset system and the fact that key documents from the Secure Training Centre were never accessed by the secure estate . The lack of a universal system of records throughout the offender’s pathway results in information on risk not being known to others and may contribute to future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Disconnection between Looked After Child pathway planning and Transition Planning
Wider context from the report “Evidence pointed to a disconnection between Looked After Child pathway planning and Transition Planning . A social worker said that the LAC plan was “potentially informative” but did not matter if it was not completed, but that now it is regarded as key and should be shared. One social worker said she did not know what a Transition Plan was. The current Head of Children's Social Care at LB Tower Hamlets said that staff pressures at the time had eased somewhat, but that under her leadership the interface with the secure estate was through the YJB and so social workers do not directly talk to the secure estate staff. This was despite the requirement for the two to work together in the Youth to Adult Transitions Framework. Given the lack of documented communications of the risks and concerns between YOT and Feltham in 2013, this evidence throws doubt on the reported improvements in training and changes in interagency communication have been put into operation since.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 propose clinical interventions
Wider context from the report “The GP did not record history or examination or propose any interventions despite being aware of the young age, long sentence and suicide warning form. The clinical review conducted as part of the Prison and Probation Ombudsman’s Report concluded that health care provision in HMP Belmarsh was below the standard expected.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 clinical history and examination
Wider context from the report “The GP did not record history or examination or propose any interventions despite being aware of the young age, long sentence and suicide warning form. The clinical review conducted as part of the Prison and Probation Ombudsman’s Report concluded that health care provision in HMP Belmarsh was below the standard expected.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 social workers to communicate directly with secure estate staff
Wider context from the report “Evidence pointed to a disconnection between Looked After Child pathway planning and Transition Planning. A social worker said that the LAC plan was “potentially informative” but did not matter if it was not completed, but that now it is regarded as key and should be shared. One social worker said she did not know what a Transition Plan was. The current Head of Children's Social Care at LB Tower Hamlets said that staff pressures at the time had eased somewhat, but that under her leadership the interface with the secure estate was through the YJB and so social workers do not directly talk to the secure estate staff . This was despite the requirement for the two to work together in the Youth to Adult Transitions Framework. Given the lack of documented communications of the risks and concerns between YOT and Feltham in 2013, this evidence throws doubt on the reported improvements in training and changes in interagency communication have been put into operation since.
” Open source report
Concerns raised 6 Failure to question unexplained SASH form transmission View source Lack of clarity about the designated recipient of SASH forms View source Failure of reception procedures under foreseeable high-demand conditions View source Failure of GEOAmey and prison reception staff to understand and keep each other informed about interconnecting procedures View source Failure of GEOAmey, prison and healthcare procedures to inter-operate safely View source Lack of a detailed, documented and tracked account of SASH form transmission View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Derek Thomas · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Derek Thomas died by suicide while in HMP Durham after arriving on remand and undergoing reception and first-night induction. Information suggesting suicidal intent was not adequately communicated or identified because of failures involving the SASH and PER forms across escort, prison reception and healthcare staff. The report raised concerns about procedures failing under demanding but foreseeable conditions, unclear inter-agency responsibilities, inadequate tracking of information, and poor interoperability between agencies.
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 question unexplained SASH form transmission
Wider context from the report “(3) That Prison reception staff in their evidence were adamant that a SASH form could never have been overlooked. However, prison staff at every level could provide no detailed, documented and tracked, account for how the SASH form had reached the prison records for Mr Thomas. There is an over reliance on the fidelity of the system, even when it has failed. No questions were asked at any stage on 21st July 2014, when it it passed from GEOAmey staff, to reception staff, to healthcare, or thereafter as to how a SASH form had arrived in the prison without being previously noticed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about the designated recipient of SASH forms
Wider context from the report “(2) That the GEOAmey staff and Prison reception staff (including very experienced officers with both) had conflicting impressions of which Prison Officer (the one dealing with the warrants and Core record alternatively the one dealing with the property and the PER) was supposed to be the recipient of the SASH form. Training and refresher training as to their own procedures notwithstanding, there is a lack of appreciation by GEOAmey escort staff of the prison's reception procedures. There is a lack of awareness by prison staff of GEOAmey staff's ignorance of them. Alternatively, the prison reception staff develop the procedures without keeping GEOAmey staff informed. There is a tangible sense of one hand not knowing what the other is doing.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure of reception procedures under foreseeable high-demand conditions
Wider context from the report “(1) That the circumstances on the 21st July 2014 at the reception included an inexperienced officer being on duty in conditions which were particularly onerous. It was described as the busiest he had ever seen by another more senior officer who was called away to deal with an incident, just at the time Mr Thomas was arriving in reception. Prison staff were adamant that another officer would have filled the gap left (although the identity of the substituting prison officer was not provided). These circumstances were clearly very demanding but they were not unforeseeable and may be repeated in future. When the procedures were “stress-tested” in the way they were on 21st July 2014, they failed so that a SASH form went unnoticed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 GEOAmey and prison reception staff to understand and keep each other informed about interconnecting procedures
Wider context from the report “(2) That the GEOAmey staff and Prison reception staff (including very experienced officers with both) had conflicting impressions of which Prison Officer (the one dealing with the warrants and Core record alternatively the one dealing with the property and the PER) was supposed to be the recipient of the SASH form. Training and refresher training as to their own procedures notwithstanding, there is a lack of appreciation by GEOAmey escort staff of the prison's reception procedures. There is a lack of awareness by prison staff of GEOAmey staff's ignorance of them. Alternatively, the prison reception staff develop the procedures without keeping GEOAmey staff informed. There is a tangible sense of one hand not knowing what the other is doing.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure of GEOAmey, prison and healthcare procedures to inter-operate safely
Wider context from the report “(5) That the above concerns go to the issue of the inter-operability of GEOAmey and prison and healthcare procedures, which is not yet addressed by any of the agencies. I note that the pilot scheme is designed to improve “information sharing” between agencies. I am concerned that this case provides a paradigm example of not just a failure in communication between agencies but a deeper failure in properly appreciating each other's procedures and potential weaknesses where they are supposed to inter-connect. Looked at holistically, the system is demonstrated to be dysfunctional in this case.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Lack of a detailed, documented and tracked account of SASH form transmission
Wider context from the report “(3) That Prison reception staff in their evidence were adamant that a SASH form could never have been overlooked. However, prison staff at every level could provide no detailed, documented and tracked, account for how the SASH form had reached the prison records for Mr Thomas. There is an over reliance on the fidelity of the system, even when it has failed. No questions were asked at any stage on 21st July 2014, when it it passed from GEOAmey staff, to reception staff, to healthcare, or thereafter as to how a SASH form had arrived in the prison without being previously noticed.
” 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 Require reception staff to physically check, read, cross-reference and jointly sign prisoner documentation before escort departure, with daily staffing records and routine observation.
Verbatim wording from the response “Reception – The Head of Operations at HMP Durham has instructed all staff working in reception that, prior to the escort contractor leaving the reception area, all documentation must be physically checked and read. The PER and all documentation must be cross referenced. It will be signed for by both staff. A daily detail is published which clearly identifies the members of staff who are working in reception on any given day and these are retained. The escort contractor has been informed of the process and is aware that the warrant and the SASH need to be handed to the supervising officer and the PER and property to the officer. All staff working in reception are expected to be competent in all areas of the process, both are situated side by side. A custodial manager and the Head of Operations will routinely observe this process.” Source location 2015-0502-Response-by-NOMS
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 Reissue and publish a reception-focused notice requiring documentation checks and warning of possible disciplinary action for failures.
Verbatim wording from the response “I note that your concerns are wider than the issues covered in the Governors Notice to Staff of 8 December 2015, however you may be interested to know that NOMS has been re-issued to primarily target reception staff. It outlines the importance of checking all documentation and advises that a failure to do so may result in disciplinary action. The Notice to Staff is published on the local prison intranet for a period of time. It is also available on the shared drive. The Head of Operations will also be positioning this on the front desk of reception for all staff working there to be constantly aware of. This will be followed up during staff’s individual performance reviews.” Source location 2015-0502-Response-by-NOMS
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 Hold monthly meetings between prison operations and the escort contractor to communicate procedural changes.
Verbatim wording from the response “Communications between agencies – The Head of Operations at HMP Durham meets with the escort contractor on a monthly basis. Any changes in procedures are communicated at this meeting. The entire contract is managed by a NOMS monitor. Escort contractor managers make on-site visits to observe the process. There are seven individual providers that make up the healthcare function. A monthly prison operational and clinical governance meeting is held and any issues between the prison and healthcare can be discussed at this meeting.” Source location 2015-0502-Response-by-NOMS
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 Hold monthly prison operational and clinical governance meetings to discuss issues between prison and healthcare services.
Verbatim wording from the response “Communications between agencies – The Head of Operations at HMP Durham meets with the escort contractor on a monthly basis. Any changes in procedures are communicated at this meeting. The entire contract is managed by a NOMS monitor. Escort contractor managers make on-site visits to observe the process. There are seven individual providers that make up the healthcare function. A monthly prison operational and clinical governance meeting is held and any issues between the prison and healthcare can be discussed at this meeting.” Source location 2015-0502-Response-by-NOMS
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 Require reception staff to complete minimum online training before working in prisoner reception, with completion managed through learning plans and appraisals.
Verbatim wording from the response “Training – All staff working in reception must complete a level of training prior to working at the point in reception where prisoners are initially received. The level of training available to reception staff is an on-line course and a classroom based course. The Head of Operations at HMP Durham has deemed that as a minimum the on-line course must be completed. This will be managed by the individual member of staff’s line manager. It will be added to their individual learning path and monitored through the staff appraisal system” Source location 2015-0502-Response-by-NOMS
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 Require reception staff to verbally hand over self-harm warnings and relevant court-return information to First Night Centre and healthcare staff.
Verbatim wording from the response “As well as the above procedures, reception staff must verbally hand over any self-harm warnings to the officer from the First Night Centre. Should a prisoner be returning from a court appearance the reception staff must verbally hand over this information directly to the health care staff. The verbal hand over is in addition to the Health Care staff receiving all of the documentation received on each prisoner.” Source location 2015-0502-Response-by-NOMS
Open published response
Concerns raised 2 Failure of healthcare staff to fully participate in suicide and self-harm risk assessment for new prisoners View source Failure to identify or properly assess suicide and self-harm risk in newly arrived prisoners 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
Daniel Brendan Byrne · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Daniel Brendan Byrne died at Milton Keynes Hospital on 27 February 2015 after being resuscitated following a suicide attempt by hanging in his cell at Woodhill Prison the previous day. The principal concerns were inadequate assessment of the risk of self-harm and suicide by healthcare staff and prison officers, failure to refer him for an urgent mental health assessment, and an inadequate first ACCT case review.
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 healthcare staff to fully participate in suicide and self-harm risk assessment for new prisoners
Wider context from the report “In the Independent Investigation Report from the Prison and Probation Ombudsman, the author refers to previous deaths at Woodhill and says:
“ Mr Byrne’s was the seventh self inflicted death at Woodhill since 2013 and there have been two since. We are concerned that many of the same issues have been repeated in a number of their investigations including this one. In six cases investigated in 2013 and 2014 we found that staff had failed to identify or properly assess the risk of suicide and self harm in newly arrived prisoners.” My concern is that during the evidence from the Nursing Staff, it appears that they did not participate fully in the health screen at reception of the first review of Mr Byrne’s ACCT . There needs to be a review of healthcare staff’s role in carrying out a full and adequate risk assessment of suicide and self-harm whenever a new prisoner is seen and assessed by healthcare . Consideration should also be given to the introduction of a formal risk assessment tool.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 or properly assess suicide and self-harm risk in newly arrived prisoners
Wider context from the report “In the Independent Investigation Report from the Prison and Probation Ombudsman, the author refers to previous deaths at Woodhill and says:
“ Mr Byrne’s was the seventh self inflicted death at Woodhill since 2013 and there have been two since. We are concerned that many of the same issues have been repeated in a number of their investigations including this one. In six cases investigated in 2013 and 2014 we found that staff had failed to identify or properly assess the risk of suicide and self harm in newly arrived prisoners .” My concern is that during the evidence from the Nursing Staff, it appears that they did not participate fully in the health screen at reception of the first review of Mr Byrne’s ACCT. There needs to be a review of healthcare staff’s role in carrying out a full and adequate risk assessment of suicide and self-harm whenever a new prisoner is seen and assessed by healthcare. Consideration should also be given to the introduction of a formal risk assessment tool.
” 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 Conduct an independent review of healthcare services, including mental health and substance misuse provision, alongside the safer custody review.
Verbatim wording from the response “In response to the recent deaths in custody at HMP Woodhill, reviews of all aspects of safer custody, and of healthcare services have been commissioned. These reviews are being conducted by staff who are not based in the prison, and the results will inform future developments.” Source location Daniel-Byrne-Response2
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct a comprehensive independent review of safer custody procedures and prison-wide factors affecting prisoner wellbeing.
Verbatim wording from the response “You have identified that the PPO has made repeat recommendations and that there is need for a comprehensive review of the safer custody procedures.” Source location Daniel-Byrne-Response2
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 Maintain a dedicated mental health team member on the First Night Centre to interview new prisoners and update identified risk factors.
Verbatim wording from the response “6. A dedicated mental health team member is now in place on the FNC Monday to Friday with plans to extend across weekends. All new prisoners will be interviewed by a member of this team. They will review the contents of the ECRA prior to prisoner interview and will also sign for the documents enclosed being present and having been read.” Source location Daniel-Byrne-Response2
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the Entry to Custody Risk Assessment process through staged reception and first-night screening, including multi-agency review and incorporation into local policy.
Verbatim wording from the response “You may be interested to know that in order to address the issues with reception screening that were identified in the case of Daniel Byrne a new tool is being introduced.” Source location Daniel-Byrne-Response2
Open published response
Concerns raised 12 Failure to monitor prisoners overnight View source Failure of prison, health and DART workers to share drug issue information adequately View source Insufficient exercise-area officer staffing for package security View source Insufficient exercise-area netting and package interception View source Failure to inform prison officers of positive drug test results View source Inadequate overnight security officer capacity for B wing View source Insufficient drug-dog coverage for screening prisoners and visitors View source Failure to check prisoners' mouths during general medicine administration View source Lack of prison officer awareness and understanding of drug issues View source Insufficient cell searching for drugs View source Lack of capability to screen incoming prisoners and visitors for concealed drugs View source Unavailability of compact drug results to DART workers View source See 9 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
Dean Ronald Edmund BOLAND · 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 Ronald Edmund Boland was found unresponsive in his cell at HMP Birmingham on 17 April 2015 and was pronounced dead shortly afterwards. Post-mortem examination confirmed multiple drugs in his system, and the inquest concluded that he died from mixed drug toxicity. The principal concerns included inadequate awareness, communication, monitoring, searching and security measures relating to drug use within the prison.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to monitor prisoners overnight
Wider context from the report “5. Prisoners on B wing are not viewed or monitored at all overnight unless they are on an ACCT . This gives them a considerable period of time to smoke and use drugs knowing there will be no supervision or observation from 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 of prison, health and DART workers to share drug issue information adequately
Wider context from the report “2. There is a lack of multi-disciplinary approach to drug issues within the prison . The evidence heard at the inquest confirmed that prison officers, health workers and DART workers do not adequately discuss trends and general drugs issues to ensure all staff are up to date and aware of the problems . It is accepted that patient’s confidentiality needs to be maintained but it is essential to discuss trends and significant events in a multi-disciplinary way.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 exercise-area officer staffing for package security
Wider context from the report “10. The prison should investigate whether 3 prison officer on duty in the exercise area is sufficient for 172 prisoners given the number of packages that are thrown over the walls every week .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 exercise-area netting and package interception
Wider context from the report “9. There are several exercise areas at the prison. Only two have netting . Further consideration needs to be given to netting other areas given the number of packages being thrown over the wall and then secreted by prisoners on their person. The inquest heard that only a small proportion of packages are seized as they come over the wall .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 prison officers of positive drug test results
Wider context from the report “8. Prison officers are unaware of positive drug test results and therefore unable to take any action in response .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 overnight security officer capacity for B wing
Wider context from the report “6. The prison deploy a security officer to B wing at night (172 prisoners) .This person is unable to interact with prisoners and is only there to answer call bells . This seems inadequate given that this group of prisoners are at high risk of drug use particularly at night when there are no cell checks.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 drug-dog coverage for screening prisoners and visitors
Wider context from the report “12. Birmingham prison has 2 drug dogs who work on a shift pattern. This means not every area in the prison can be covered as only one dog is on duty at any one time . Given that these dogs are the only current mechanism for identifying certain drugs consideration needs to be given to having more dogs so that prisoners and visitors coming into the prison will always be screened .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 prisoners' mouths during general medicine administration
Wider context from the report “3. General medicine administration does not involve a check of the mouth so prisoners can easily conceal tablets to sell later .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 awareness and understanding of drug issues
Wider context from the report “1. There was a general lack of awareness and understanding of the drugs issues in the prison by prison officers . Two prison officers who worked on B wing said they were unaware of any problems with prisoners using illicit drugs including general medications . Prison officers need a comprehensive education program to understand what drugs are being used and sold and how prisoners come by those drugs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 cell searching for drugs
Wider context from the report “4. Cell searches only take place for a certain number of cells each month on a random basis as prescribed by NOMS, or for targeted cells when there is sufficient intelligence . Intelligence searches only take place when there is at least 2 pieces of intelligence . Given the extent of the drug problem on B wing this seems insufficient .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 capability to screen incoming prisoners and visitors for concealed drugs
Wider context from the report “11. At present there is no ability to search or screen prisoners or visitors for drugs concealed on their person when they come into prison . Given that this is a major source of drugs coming into the prison further consideration need to be given, on a national level, as to how concealed drugs can be identified for example with the use of a full body scanner. The current scanner can only identify metal objects .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 compact drug results to DART workers
Wider context from the report “7. DART workers are currently unable to access compact drug results as workers are unable to log onto the computer .
” 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 Hold monthly drug-strategy meetings, require B-Wing officers to attend, and require detox and recovery staff to confirm they have read the minutes.
Verbatim wording from the response “Drug strategy meetings are being held monthly and the purpose of these meetings is to discuss current issues and trends around drug misuse within the prison and to agree actions and strategies going forward. These meetings are attended by a cross-functional group of interested parties including clinical staff, residential managers and DART workers. From 9 December 2015 there has been mandatory attendance at these meetings from prison officers who work on B Wing. All staff on the detox and recovery unit will be required to sign a document indicating that they have read the minutes of the meeting each month. Also included in this meeting is discussion of those prisoners receiving opiate substitution medications who have failed both mandatory and compliance based drugs tests.” Source location 2015-0468-Response-by-NOMS
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 Observe and record medication swallowing, supplementing opioid-substitution administration with mouth checks and officer presence to address concealment concerns.
Verbatim wording from the response “Administration of IDTS medication is supplemented by a check of the mouth in line with the compact signed by IDTS recipients to comply with their treatment pathway. This is similar to supervised consumption being requested by the prescriber in the community.” Source location 2015-0468-Response-by-NOMS
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 Train specialist dogs to search for and detect new psychoactive substances in prisons.
Verbatim wording from the response “substances. It includes a new offence of possession of a psychoactive substance in a custodial institution, which will tackle the dangerous and pervasive use of new psychoactive substances in prisons. The Government recently commenced a clause in the Serious Crime Act, which introduces a new offence of throwing any item over a prison wall, including psychoactive substances. Plans are in place to provide widespread testing for psychoactive substances as part of the MDT process by April 2016, and NOMS has trained more than 300 specialist dogs to search and detect new psychoactive substances in prisons. NOMS is also evaluating the effectiveness of body scanners to tackle further the threat posed by drugs being smuggled into prisons.” Source location 2015-0468-Response-by-NOMS
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 Evaluate body-scanner effectiveness for tackling drugs smuggled into prisons.
Verbatim wording from the response “substances. It includes a new offence of possession of a psychoactive substance in a custodial institution, which will tackle the dangerous and pervasive use of new psychoactive substances in prisons. The Government recently commenced a clause in the Serious Crime Act, which introduces a new offence of throwing any item over a prison wall, including psychoactive substances. Plans are in place to provide widespread testing for psychoactive substances as part of the MDT process by April 2016, and NOMS has trained more than 300 specialist dogs to search and detect new psychoactive substances in prisons. NOMS is also evaluating the effectiveness of body scanners to tackle further the threat posed by drugs being smuggled into prisons.” Source location 2015-0468-Response-by-NOMS
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete drug-awareness training for prison staff by 31 January 2016.
Verbatim wording from the response “Prison officers need a comprehensive education program to understand what drugs are being used and sold and how prisoners consume them
Following the inquest, training on supervising the administration of opiate substitution medication has been completed with detox unit staff and drug awareness training is scheduled for completion by 31 January 2016.” Source location 2015-0468-Response-by-NOMS
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 Undertake collaborative work with West Midlands Police to close the prison’s most significant illicit-substance ingress point.
Verbatim wording from the response “Only two exercise yards have netting. Further consideration needs to be given to netting other areas given the number of packages being thrown over the wall and then secreted by prisoners on their person. Only a small proportion of packages are seized as they come over the wall.
Preventing illicit articles from entering the prison is a key part of the prison’s supply reduction strategy, and a vast amount of work has been undertaken, in conjunction with West Midlands Police, on closing down the most significant ingress point, where the establishment considers it necessary it can submit bids for capital expenditure, and it would do so if it believed that additional security measures would make an impact on supply.” Source location 2015-0468-Response-by-NOMS
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 Discuss drug-misuse trends in monthly drug-strategy and security meetings and identify and implement risk-reduction actions.
Verbatim wording from the response “Issues around the misuse of illicit drugs and prescribed medication are discussed during monthly drug strategy and security meetings. During the meeting trends and issues around drug misuse of all kinds are discussed and actions to reduce the risk and likelihood of these occurrences are identified and put in place. Due consideration is given to confidentiality, but this does not prevent discussion around these issues.” Source location 2015-0468-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 Increasing exercise supervision is not considered necessary because staffing levels are risk assessed and additional staff would not be the best use of resources.
Verbatim wording from the response “The prison should investigate whether 3 prison officers on duty in the exercise area is sufficient for 172 prisoners given the number of packages that are thrown over the walls every week.
Staffing levels for exercise are risk assessed appropriately. B wing exercise yard has no external ingress point; the detox wing was moved to B wing on account of this, so that no throw overs can reach the exercise yard. Increasing the number of staff supervising exercise is not felt to be necessary, and it would not be the best use of resources.” Source location 2015-0468-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 There is no clinical requirement to check prisoners’ mouths when administering controlled or general medication.
Verbatim wording from the response “Controlled drug administration is carried out by two nursing staff in line with medicine code policy. There is no clinical requirement to check the mouth of prisoners. However, in accordance with the published standard operating procedure, the designated practitioner observes the prisoner taking his medication and annotates the medication chart to indicate that it has been taken and swallowed.” Source location 2015-0468-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 No additional night staff are planned because current deployment exceeds contractual requirements and provides access to senior and clinical staff.
Verbatim wording from the response “Prisoners on B Wing are not viewed or monitored overnight unless they are on an ACCT giving them a considerable period of time to smoke and use drugs
Across the prison service there is no routine night time monitoring for prisoners other than those subject to the Assessment, Care in Custody and Teamwork (ACCT) case management process and those who are segregated or located on an inpatient ward. It is important that during night state the reduced numbers of staff are deployed to supervise those most vulnerable or at risk.” Source location 2015-0468-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 Four drug dogs are deployed strategically according to intelligence and risk, including searches of prisoners, visitors, cells and targeted areas.
Verbatim wording from the response “Consideration needs to be given to having more dogs so that prisoners and visitors coming into the prison will always be screened
HMP Birmingham has four operational drug dogs at its disposal. There are two dog handlers each of whom has two drug dogs: a passive drug dog (trained to search people) and an active drug dog (trained to search areas).” Source location 2015-0468-Response-by-NOMS
Open published response
Concerns raised 3 Failure of clinicians to review patients’ historical medical records View source Failure of SystmOne to provide usable search and clear flagging of important historical information View source Lack of a reliable tool for assessing depression in prisoners View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Richard Scott Green · 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
Richard Scott Green was found hanged in his cell at Haverigg Prison on 9 May 2014, using a ligature made from a torn bed sheet. The jury found that bullying and debt had contributed to his death but was not satisfied that he intended to kill himself. The report raised concerns that his documented history of self-harm and apparent suicide attempts was not recognised or acted upon by prison medical professionals, with missed opportunities to assess and manage the risk he presented.
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 clinicians to review patients’ historical medical records
Wider context from the report “I was clear that serious incidents of self-harm/suicide attempts from 2007 and 2013 were recorded on his SystmOne records. These do not appear to have been recognised or acted upon by various medical professionals in the prison system.
This meant that a nurse at screening had not read the records, neither had a GP or a mental health nurse who later carried out an assessment. The result was that throughout his prison term at Haverigg no one was aware of the history and the risk he presented. As a result, there were missed opportunities which might have made a difference. Evidence showed that
a) there appeared to be no reliable tool to help assess depression in a prisoner (community tools being unsatisfactory).
b) Although entries were there to be seen on System One, none of the clinicians saw them. Pressure of work and the time needed to check were reasons cited, together with lack of resources.
It seems SystmOne was not easy to use, some staff being unaware they could “search” and an absence of a way to clearly flag important historical information to ensure it was at the clinicians’ finger tips.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure of SystmOne to provide usable search and clear flagging of important historical information
Wider context from the report “I was clear that serious incidents of self-harm/suicide attempts from 2007 and 2013 were recorded on his SystmOne records. These do not appear to have been recognised or acted upon by various medical professionals in the prison system.
This meant that a nurse at screening had not read the records, neither had a GP or a mental health nurse who later carried out an assessment. The result was that throughout his prison term at Haverigg no one was aware of the history and the risk he presented. As a result, there were missed opportunities which might have made a difference. Evidence showed that
a) there appeared to be no reliable tool to help assess depression in a prisoner (community tools being unsatisfactory).
b) Although entries were there to be seen on System One, none of the clinicians saw them. Pressure of work and the time needed to check were reasons cited, together with lack of resources.
It seems SystmOne was not easy to use, some staff being unaware they could “search” and an absence of a way to clearly flag important historical information to ensure it was at the clinicians’ finger tips.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 tool for assessing depression in prisoners
Wider context from the report “I was clear that serious incidents of self-harm/suicide attempts from 2007 and 2013 were recorded on his SystmOne records. These do not appear to have been recognised or acted upon by various medical professionals in the prison system.
This meant that a nurse at screening had not read the records, neither had a GP or a mental health nurse who later carried out an assessment. The result was that throughout his prison term at Haverigg no one was aware of the history and the risk he presented. As a result, there were missed opportunities which might have made a difference. Evidence showed that
a) there appeared to be no reliable tool to help assess depression in a prisoner (community tools being unsatisfactory).
b) Although entries were there to be seen on System One, none of the clinicians saw them. Pressure of work and the time needed to check were reasons cited, together with lack of resources.
It seems SystmOne was not easy to use, some staff being unaware they could “search” and an absence of a way to clearly flag important historical information to ensure it was at the clinicians’ finger tips.
” Open source report
Concerns raised 11 Serious drug problem in the prison View source Failure of healthcare and discipline staff to know the overdose policy and prescribed response View source Complacency about prisoners presenting under the influence of drugs View source Failure to request emergency attendance by the on-duty nurse View source Failure of healthcare and discipline staff to provide an integrated response to drug-related presentations View source Failure to prepare an ongoing treatment plan for prisoners receiving nursing care View source Lack of formal training and detailed understanding of the current overdose policy View source Inadequate recording of nursing care and required actions View source Lack of operational guidance for responding to suspected overdoses View source Complacency and acceptance by staff of the prison drug problem View source Delays and uncertainty in calling an emergency ambulance and using the code blue call View source See 8 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Kevin Anthony Forster · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Kevin Anthony Forster died in his prison cell at HMP Durham on 14 September 2014 after taking drugs he had hidden within his body. Staff identified that he was under the influence of an unknown substance, but no thorough or clinical assessment was undertaken. The principal concerns included inadequate policies, training, assessment, observation, treatment planning, communication and emergency response to prisoners who may have overdosed.
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 Serious drug problem in the prison
Wider context from the report “1. It was clear from evidence that there is a serious drug problem in HMP Durham . This has led to a degree of complacency and acceptance by staff of that situation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 and discipline staff to know the overdose policy and prescribed response
Wider context from the report “2. Healthcare staff were unaware of what, if any, drugs policy was in place at the time . A policy known as a “Drugs Overdose Policy” which had, in various guises been in operation since 2008 included a definition of overdose as the “purposeful or accidental act of ingesting an amount of a drug or substance that may cause harm to health”. As such, the ingestion of unknown drugs is de facto harmful to health and would constitute an overdose which should lead to the triggering of the Overdose Policy. Both discipline and healthcare staff were unaware of the policy, the “overdose” definition and the prescribed steps which should then ensue .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Complacency about prisoners presenting under the influence of drugs
Wider context from the report “9. As mentioned earlier the evidence indicated that there was a degree of complacency about prisoners presenting under the influence of drugs and the risks associated therewith (at handover one officer said to another “there are some prisoners sleeping it off”). Due to the scale of the issue, the potential risk to health of prisoners is such that there needs to be absolute clarity of response and care for prisoners who so present. The evidence indicated that a more integrated approach between healthcare staff and discipline staff would be beneficial notwithstanding there were good lines of communication between the two.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 request emergency attendance by the on-duty nurse
Wider context from the report “7. Discipline staff summoned healthcare staff and perhaps not appreciating the significance of the apparent health of the deceased, did not call for the on-duty nurse to attend as an emergency, but just asked for the nurse to attend . Such an oversight could lead to a delay which in certain circumstances might be very significant.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 and discipline staff to provide an integrated response to drug-related presentations
Wider context from the report “9. As mentioned earlier the evidence indicated that there was a degree of complacency about prisoners presenting under the influence of drugs and the risks associated therewith (at handover one officer said to another “there are some prisoners sleeping it off”). Due to the scale of the issue, the potential risk to health of prisoners is such that there needs to be absolute clarity of response and care for prisoners who so present. The evidence indicated that a more integrated approach between healthcare staff and discipline staff would be beneficial notwithstanding there were good lines of communication between the two.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 prepare an ongoing treatment plan for prisoners receiving nursing care
Wider context from the report “6. There was a lack of an on-going treatment plan prepared for the deceased by nursing staff who attended on him and there was inadequate recording that they had done and what they had to do.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 and detailed understanding of the current overdose policy
Wider context from the report “3. Upon obtaining the contract for healthcare at HMP Durham, G4S have instituted have implemented a new policy, but evidence was given that staff had not been given any formal training on it , though the document (running to 12 pages) had been emailed. Evidence indicated that there was still a lack of appreciation of the detail of the policy now in force .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Inadequate recording of nursing care and required actions
Wider context from the report “6. There was a lack of an on-going treatment plan prepared for the deceased by nursing staff who attended on him and there was inadequate recording that they had done and what they had to do .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 operational guidance for responding to suspected overdoses
Wider context from the report “4. The evidence indicated that there was a lack of guidance as to how staff should react when faced with a person who had overdosed ; no local procedures as envisaged by the policy were disclosed , what should be done where there is no indicator as to what substance had been ingested and what would be the appropriate level of observations recognising that (Policy paragraph 8.1) symptoms may develop later .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Complacency and acceptance by staff of the prison drug problem
Wider context from the report “1. It was clear from evidence that there is a serious drug problem in HMP Durham. This has led to a degree of complacency and acceptance by staff of that situation .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Delays and uncertainty in calling an emergency ambulance and using the code blue call
Wider context from the report “8. The evidence indicated that there was a delay (albeit a short one) in either healthcare or discipline staff calling for an emergency ambulance to attend and/or whether code blue as an expression was used . Other inquests have clearly identified issues at the establishment about the calling of an emergency ambulance.
” Open source report
Concerns raised 6 Lack of prison officer training on choking risks during searches and control and restraint View source Lack of prison officer training on choking risks during searches and control and restraint View source Failure to provide the attending ambulance service with the prison gate location View source Failure of prison control room officers to immediately provide ambulance access-gate locations to emergency call handlers View source Unavailability of alternative prison-gate information in LAS call-handler systems for other London prisons View source Failure of Hotel 7 nurses to respond immediately to every emergency alarm View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Adil HABIB · 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
Adil Habib died at HMP Pentonville after swallowing a package containing crack cocaine during a search while subject to control and restraint; he choked on it. The inquest recorded the death as accidental, with acute respiratory failure due to mechanical obstruction of the upper airway by a foreign object. A concern was raised that the 999 caller did not immediately provide the prison gate location for attending paramedics, and that ambulance call-handling systems did not then show alternative gates for all London 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 prison officer training on choking risks during searches and control and restraint
Wider context from the report “I heard evidence at inquest that there is no training for prison officers that specifically covers the risk of prisoners choking as a result of attempts to conceal an item from prison officers, most especially during a search and/or control & restraint . It seems to me that this is a significant omission , and it would be helpful if such training were mandatory and refreshed regularly. I have written to the National Offender Management Service as provider of prison officer training about this but, in addition, I wanted to bring this direct to your attention. It may be some months before there is any change to the national training offered.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 choking risks during searches and control and restraint
Wider context from the report “I heard evidence at inquest that there is no training for prison officers that specifically covers the risk of prisoners choking as a result of attempts to conceal an item from prison officers, most especially during a search and/or control & restraint . It seems to me that this is a significant omission, and it would be helpful if such training were mandatory and refreshed regularly.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 the attending ambulance service with the prison gate location
Wider context from the report “When a prison officer at HMP Pentonville rang 999 to ask that paramedics attend the prison, the caller did not immediately offer the location of the prison gate that London Ambulance Service should attend . Whilst there is of course an issue for the prison in terms of offering the information , it would be helpful for LAS call handlers to be provided with a drop down menu showing the alternative gates when they input the prison details.
I understand that the LAS computer system has been augmented in this respect since Mr Habib’s death for HMP Pentonville, but not for the other London prisons. Perhaps that would be a useful 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 of prison control room officers to immediately provide ambulance access-gate locations to emergency call handlers
Wider context from the report “The prison officer who rang 999 from the control room did not immediately offer the LAS call handler the location of the prison gate to which the ambulance should be driven . I understand that your team has taken steps to remind all officers working in the control room that they must do this. I understand also that your team has an ongoing conversation with London Ambulance Service to enable best care to be given to those in the prison in need of paramedic attention.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 alternative prison-gate information in LAS call-handler systems for other London prisons
Wider context from the report “When a prison officer at HMP Pentonville rang 999 to ask that paramedics attend the prison, the caller did not immediately offer the location of the prison gate that London Ambulance Service should attend. Whilst there is of course an issue for the prison in terms of offering the information, it would be helpful for LAS call handlers to be provided with a drop down menu showing the alternative gates when they input the prison details.
I understand that the LAS computer system has been augmented in this respect since Mr Habib’s death for HMP Pentonville, but not for the other London prisons . Perhaps that would be a useful 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 of Hotel 7 nurses to respond immediately to every emergency alarm
Wider context from the report “The nurse who was on call as Hotel 7 at the prison did not respond to the emergency alarm that was activated at the start of the control & restraint of Mr Habib, as she should have . Instead, she only responded once a Level 1 emergency was radioed . I appreciate that this nurse no longer works at HMP Pentonville and that your team has taken steps to remind all nurses operating as Hotel 7 of their responsibility to respond to every alarm immediately.
” 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 Send the DVD and a Notice to Governors to all prison Governors for viewing by operational staff.
Verbatim wording from the response “The DVD will be sent to all prison Governors by Christmas along with a Notice to Governors advising them of the content and that it should be made available for all operational staff to view. The content will be reinforced in due course when all operation staff receive updated control and restraint training from the National Control & Restraint Instructors. It is expected that the roll out of training will commence in January 2016. All Prison Officer Entry Level Trainees (POELTs) will receive training relating to the contents of this DVD from in December.” Source location 2015-0380-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 Consult key stakeholders on the accompanying training material for the control and restraint DVD.
Verbatim wording from the response “I can confirm that the DVD has been completed and that the accompanying training material has been prepared and is out for consultation with key stakeholders. I can also confirm that the DVD includes medical advice related to the use of control and restraint and covers:” Source location 2015-0380-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 Complete a training DVD covering medical advice and safe use of control and restraint.
Verbatim wording from the response “In your letter you raise concern that the national training for search and restraint does not cover those situations where a prisoner is at risk of choking after attempting to conceal an item during control and restraint procedures. You will be aware that the Chief Executive of NOMS accepted the Prisons and Probation Ombudsman’s recommendation that clear guidance and training be given on the safe use of force, including pain compliance techniques, when resistant prisoners have items in their mouths, which might compromise their breathing. In the response, NOMS confirmed that a DVD was being produced to aid staff training in the safe use of force, in conjunction with current medical advice, and that NOMS would consider the best way to include specific guidance within the DVD on what action should be taken where items are concealed in a resistant prisoner’s mouth.” Source location 2015-0380-Response-by-NOMS
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide updated control and restraint training to operational staff through National Control & Restraint Instructors.
Verbatim wording from the response “The DVD will be sent to all prison Governors by Christmas along with a Notice to Governors advising them of the content and that it should be made available for all operational staff to view. The content will be reinforced in due course when all operation staff receive updated control and restraint training from the National Control & Restraint Instructors. It is expected that the roll out of training will commence in January 2016. All Prison Officer Entry Level Trainees (POELTs) will receive training relating to the contents of this DVD from in December.” Source location 2015-0380-Response-by-NOMS
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide Prison Officer Entry Level Trainees with training on the DVD’s contents.
Verbatim wording from the response “The DVD will be sent to all prison Governors by Christmas along with a Notice to Governors advising them of the content and that it should be made available for all operational staff to view. The content will be reinforced in due course when all operation staff receive updated control and restraint training from the National Control & Restraint Instructors. It is expected that the roll out of training will commence in January 2016. All Prison Officer Entry Level Trainees (POELTs) will receive training relating to the contents of this DVD from in December.” Source location 2015-0380-Response-by-NOMS
Open published response
Concerns raised 3 Failure to provide timely clarification of prisoners’ sentence lengths View source Failure to accurately calculate prisoners’ sentences under the applicable statutory provisions View source Failure to maintain current first-aid training for prison staff working alone at night View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Luke Myers · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Luke Myers was found hanging from a bunk-bed in his prison cell on 4 February 2013 and was pronounced dead after resuscitation attempts were unsuccessful. The report raised concerns about the miscalculation of his sentence, which the inquest jury found was a likely factor in his death, and about the length of time since prison discipline staff had received first-aid 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 Failure to provide timely clarification of prisoners’ sentence lengths
Wider context from the report “(1) HMP Liverpool miscalculated Luke Myer's extended sentence of 12 years from November 2012 by erroneously applying Section 226A CJA 2003 and with regard to parole section 246A CJA 2003. The sentence was under section 227 CJA 2003 – Are there any other prisoners sentenced at that transitional time who believe they have a longer sentence than the law prescribed? Luke Myers tried to clarify his length of sentence during his life and it was only clarified during his inquest. The jury found this was a likely factor in his death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to accurately calculate prisoners’ sentences under the applicable statutory provisions
Wider context from the report “(1) HMP Liverpool miscalculated Luke Myer's extended sentence of 12 years from November 2012 by erroneously applying Section 226A CJA 2003 and with regard to parole section 246A CJA 2003. The sentence was under section 227 CJA 2003 – Are there any other prisoners sentenced at that transitional time who believe they have a longer sentence than the law prescribed? Luke Myers tried to clarify his length of sentence during his life and it was only clarified during his inquest. The jury found this was a likely factor in his death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain current first-aid training for prison staff working alone at night
Wider context from the report “(2) During the course of the inquest evidence was heard from two members of Prison discipline staff that they had last been trained in first aid respectively 10 and 6 years ago . In other circumstances this could have had an effect on the outcome. At night officers can be lone working on a wing and presumably you would agree that it would be desirable for any such officer to be first aid trained . First aid training in low hazardous work place environments is usually certified for three years before refresher requalification is needed . You consideration and plan for first aid training in prisons would be very welcome.
” 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 sentence calculations for the current prisoner population to identify miscalculated sentences.
Verbatim wording from the response “Staff at HMP Liverpool miscalculated Luke Myer’s extended sentence and may have done so in other cases
I can confirm that staff in the Offender Management Unit at HMP Liverpool have reviewed the sentence calculations for the current population and found no other prisoners to have a miscalculated sentence.” Source location 2015-0292-Response-by-Ministry-of-Justice
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 first aid training to Operational Support Grade staff.
Verbatim wording from the response “First Aid Training
Individual establishments carry out a risk assessment to determine how many, and which, staff should be trained in ‘First aid at work’. HMP Liverpool has 24 hour healthcare cover, and this is sufficient to meet the identified needs. All nursing staff are qualified nurses and hold an ‘Intermediate life support’ qualification as part of their training. In addition, first aid training is being provided to all Custodial Managers who carry out orderly officer duties, ensuring that there will be an additional trained member of staff on duty at all times, and Operational Support Grade staff will also be trained.” Source location 2015-0292-Response-by-Ministry-of-Justice
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 first aid training to all Custodial Managers undertaking orderly officer duties.
Verbatim wording from the response “First Aid Training
Individual establishments carry out a risk assessment to determine how many, and which, staff should be trained in ‘First aid at work’. HMP Liverpool has 24 hour healthcare cover, and this is sufficient to meet the identified needs. All nursing staff are qualified nurses and hold an ‘Intermediate life support’ qualification as part of their training. In addition, first aid training is being provided to all Custodial Managers who carry out orderly officer duties, ensuring that there will be an additional trained member of staff on duty at all times, and Operational Support Grade staff will also be trained.” Source location 2015-0292-Response-by-Ministry-of-Justice
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 No other prisoners were found to have miscalculated sentences after reviewing current population sentence calculations.
Verbatim wording from the response “Staff at HMP Liverpool miscalculated Luke Myer’s extended sentence and may have done so in other cases
I can confirm that staff in the Offender Management Unit at HMP Liverpool have reviewed the sentence calculations for the current population and found no other prisoners to have a miscalculated sentence.” Source location 2015-0292-Response-by-Ministry-of-Justice
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 Twenty-four-hour healthcare cover is sufficient to meet identified first-aid training needs at HMP Liverpool.
Verbatim wording from the response “First Aid Training
Individual establishments carry out a risk assessment to determine how many, and which, staff should be trained in ‘First aid at work’. HMP Liverpool has 24 hour healthcare cover, and this is sufficient to meet the identified needs. All nursing staff are qualified nurses and hold an ‘Intermediate life support’ qualification as part of their training. In addition, first aid training is being provided to all Custodial Managers who carry out orderly officer duties, ensuring that there will be an additional trained member of staff on duty at all times, and Operational Support Grade staff will also be trained.” Source location 2015-0292-Response-by-Ministry-of-Justice
Open published response
Concerns raised 3 Lack of adequate healthcare resources for prison re-rolls View source Lack of preparation for prison re-rolls View source Inability of prison staff to cope with transferred prisoner populations 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
David James Hallet · 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
David James Hallet was serving a prison sentence when he was transferred to HMP Rye Hill, admitted to hospital and diagnosed with metastatic pancreatic cancer. He later died at HMP Parc after being transferred to its palliative care suite; concerns included inadequate healthcare at HMP Rye Hill, linked in the report to insufficient preparation and resources for a national prison re-roll.
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 adequate healthcare resources for prison re-rolls
Wider context from the report “• The evidence indicated that one of the primary reasons for this was lack of preparation by the Prison Authorities staff and an inability to cope with the types of prisoners who were transferred to HMP Rye Hill. The clinical review undertaken by Healthcare Inspectorate Wales was critical of the care he received at HMP Rye Hill and the evidence clearly indicated that a lack of preparation for the re-roll and the lack of adequate resources were the primary reason for this substandard care.
• Whilst it is appreciated that HMP Rye Hill may not be subject to a further re-roll it is of concern that other re-rolls nationally may be being considered and which may conceivably give rise to issues similar to those presented in this case.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Lack of preparation for prison re-rolls
Wider context from the report “• The evidence indicated that one of the primary reasons for this was lack of preparation by the Prison Authorities staff and an inability to cope with the types of prisoners who were transferred to HMP Rye Hill. The clinical review undertaken by Healthcare Inspectorate Wales was critical of the care he received at HMP Rye Hill and the evidence clearly indicated that a lack of preparation for the re-roll and the lack of adequate resources were the primary reason for this substandard care.
• Whilst it is appreciated that HMP Rye Hill may not be subject to a further re-roll it is of concern that other re-rolls nationally may be being considered and which may conceivably give rise to issues similar to those presented in this case.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Inability of prison staff to cope with transferred prisoner populations
Wider context from the report “• The evidence indicated that one of the primary reasons for this was lack of preparation by the Prison Authorities staff and an inability to cope with the types of prisoners who were transferred to HMP Rye Hill . The clinical review undertaken by Healthcare Inspectorate Wales was critical of the care he received at HMP Rye Hill and the evidence clearly indicated that a lack of preparation for the re-roll and the lack of adequate resources were the primary reason for this substandard care.
• Whilst it is appreciated that HMP Rye Hill may not be subject to a further re-roll it is of concern that other re-rolls nationally may be being considered and which may conceivably give rise to issues similar to those presented in this case.
” Open source report
Concerns raised 16 Unavailability of enhanced criminal-record disclosures for overseas armed private security employment View source Lack of recording of pre-conviction disclosures View source Lack of understanding of overseas armed close protection work View source Lack of guidance and transfer arrangements for MAPPA-triggering offenders View source Lack of computer categorisation for close protection occupations View source Lack of clear procedure and funding responsibility for independent forensic psychiatric reports View source Lack of training for officers and civilian employees on disclosure procedures View source Failure to understand and operate the Notifiable Occupation Scheme View source Failure to consider disclosure to employers View source Inadequate and infrequent formal supervision of newly qualified offender managers View source Lack of a national system and contact point for obtaining military information View source Failure to record discussions among key professionals View source Failure of agencies to check and share available information before multi-agency meetings View source Incomplete and unclear procedure for the Common Law Police Disclosure Scheme View source Misunderstanding of residence conditions for offender monitoring View source Lack of recording of offenders' bail conditions View source See 13 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
Paul Mc Guigan · 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
Paul Mc Guigan was shot and unlawfully killed by a close protection work colleague on 9 August 2009 while both were working as armed private security contractors in Baghdad. The report identified missed opportunities and failings in managing the offender’s escalating offending behaviour and risk, and stated that G4S had not adequately vetted him before deployment. Concerns also included failures in information sharing, recording bail conditions, police disclosure processes, and the supervision and risk assessment of offenders.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Unavailability of enhanced criminal-record disclosures for overseas armed private security employment
Wider context from the report “I also have a concern that an employer on a private security contract at home has regulated by the SIA and a private security employed overseas [unregulated save for voluntary schemes such as International Code of Conduct for Private Security Service Providers 2010 [ICoC] and accredited certification to the standard ANSI/ SSlS PSC. 1-2012] is not entitled or able to obtain an enhanced CRB and would only ever receive a Standard disclosure on a pre employment check.
It concerns me in particular that in respect of employing on individual on an armed contract then consideration should be given to enabling Private Security Companies a route to obtaining an enhanced disclosure.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 recording of pre-conviction disclosures
Wider context from the report “It is clear that within GMP there was no recording anywhere as to when / if any pre convictions disclosures were made . It is important that there is a system of recording in this scenario and also to whom the disclosure is made. At present no-one can provide any information as to the number of detail of pre-conviction disclosures. In addition this means that officers who may be dealing with someone who has been arrested have no way of knowing if such a pre-conviction disclosure has ever been made.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of overseas armed close protection work
Wider context from the report “In addition I have a concern that there is a complete lack of understanding by the Police and Probation / NOMS as to what close protection work overseas involves and in particular when this involves work on armed contracts .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance and transfer arrangements for MAPPA-triggering offenders
Wider context from the report “It concerns me to ensure that there is clear guidance given by NOMS to the private community rehabilitation companies [e.g. in Manchester Purple Futures] as to assessment of risk and for offenders who then do trigger MAPPA concerns that should be being supervised or assessed for eligibility under MAPPA to be transferred to be supervised by the National Probation Service.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 computer categorisation for close protection occupations
Wider context from the report “In respect of the GMP computer system and in respect of occupations that are regulated and require licensing by the SIA, there is no categorisation on the computer for “CLOSE PROTECTION” . Indeed the Court heard that there was some confusion and lack of understanding from many people as to what this occupation actually meant. Close protection work is a separate category of employment within the UK that the SIA regulates and the police system should reflect the occupations subject to regulation. It is important that the police and NOMS have a clear understanding as to what close protection work is to inform risk and risk assessment.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Lack of clear procedure and funding responsibility for independent forensic psychiatric reports
Wider context from the report “It concerns me that there is not a clear practice and procedure operating within the Court or probation system, including funding responsibility, for obtaining an Independent Forensic Psychiatric Report , particularly in circumstances where a defendant is remanded on bail in the community.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Lack of training for officers and civilian employees on disclosure procedures
Wider context from the report “At present in respect of a replacement scheme in respect of clarifying the Common Law Police Disclosure Scheme I heard evidence as to the process GMP are undergoing in respect of a revised Procedure relating to Notifiable Occupations but this is far from complete and less than clear as to how it will operate and the training that will be given to officers / GMP civilian employees . The Court was also advised that at no stage has legal advice been taken from the force in-house legal team on the proposed scheme, even though this is a difficult legal area.
It is important that GMP and all forces have a recognised procedure in respect of having a scheme but also training officers to operate that scheme. It is imperative also that the SIA understand how and when each police force will be making disclosures under the Common Law Police Disclosure Scheme.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to understand and operate the Notifiable Occupation Scheme
Wider context from the report “In my judgment there was a complete misunderstanding by GMP in respect of the operation of the Notifiable Occupation Scheme HOC 6/2006 .
Of immense concern also the complete failure for a period of approximately 18 months to make any post conviction notifications under the Notifiable Occupation Scheme , which was it transpired, formally withdrawn by the Home Secretary Theresa May MP in March 2015.
I heard and received evidence from the SIA that they were not aware that a regulatory gap existed in respect of the Police’s understanding of the scheme and notifications to themselves . The evidence I heard suggests that such a gap exists at GMP and has done so for in excess of 18 months.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to consider disclosure to employers
Wider context from the report “In respect of the period of time when Post conviction disclosures were made [before this “back office” function ceased 18 months ago] these were only ever disclosures made to the Regulatory body and consideration never appears to have been given within GMP to disclosure to employers . Given the lack of understanding as to whom some regulatory bodies have responsibility for, this is important.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Inadequate and infrequent formal supervision of newly qualified offender managers
Wider context from the report “I heard evidence that the Offender Manager was newly qualified and her formal supervision was inadequate and infrequent . This concerns me. It is important that newly qualified offender managers receive appropriate formal 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 Lack of a national system and contact point for obtaining military information
Wider context from the report “My concern is to ensure that there is a system, protocol and point of contact for every offender manager nationally [including the private rehabilitation companies now operating as offender managers] that is well known as to who to contact to within the Ministry of Defence to obtain military information .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to record discussions among key professionals
Wider context from the report “In addition I heard evidence and it concerns me that in advance of the Multi Agency meeting convened due to concerns as to the Offenders risk, key professionals had had discussions, telephone calls and meetings and I was concerned by the failure to record and document these important discussions , to ensure clarity, understanding and consistency. It is important when key professionals have discussions that these are documented and recorded .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure of agencies to check and share available information before multi-agency meetings
Wider context from the report “It is important irrespective of who is the lead agency at a Multi Agency Meeting that each agency invited to attend checks information held on systems and records to which they have access and provides all this information to a multi agency meeting to ensure that a full and informed assessment of risk takes place and the fullest possible informed information sharing.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Incomplete and unclear procedure for the Common Law Police Disclosure Scheme
Wider context from the report “At present in respect of a replacement scheme in respect of clarifying the Common Law Police Disclosure Scheme I heard evidence as to the process GMP are undergoing in respect of a revised Procedure relating to Notifiable Occupations but this is far from complete and less than clear as to how it will operate and the training that will be given to officers / GMP civilian employees. The Court was also advised that at no stage has legal advice been taken from the force in-house legal team on the proposed scheme, even though this is a difficult legal area.
It is important that GMP and all forces have a recognised procedure in respect of having a scheme but also training officers to operate that scheme. It is imperative also that the SIA understand how and when each police force will be making disclosures under the Common Law Police Disclosure Scheme.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Misunderstanding of residence conditions for offender monitoring
Wider context from the report “I also heard evidence that a GMP officer believed that Bail with a condition of residence was different to “bail live and sleep each night”. It is of concern that there is a misunderstanding within GMP as to what a condition of residence means and how this relates to the monitoring of offenders .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 recording of offenders' bail conditions
Wider context from the report “I heard evidence that in respect of GMP systems and processes there was nowhere on the GMP computer system where bail conditions are recorded , although this used to be possible. It is of concern that there is no system of recording on the GMP computer of offenders bail conditions so that this information can be known by officers and appropriately shared.
” Open source report
17 Apr 2015 Mark Groombridge · Prevention of Future Deaths report Staffordshire South
View report summary
Concerns raised 2 Probation staff lacking a correct understanding of the recall process View source Lack of direct communication between offender managers and hospital clinicians before recall decisions 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
Mark Groombridge · 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 Groombridge was in the community on licence from prison when a recall warrant was issued. He was arrested while an inpatient in a psychiatric unit and taken to HMP Dovegate, where he died by suicide on 27 December 2013 after jumping head first from a bed in the prison health care centre. The concerns identified included a lack of direct communication between the local offender manager and the clinician before recall paperwork was issued, and confusion among probation staff about the recall process.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Probation staff lacking a correct understanding of the recall process
Wider context from the report “(2) There was confusion about the recall process. The local offender manager believed that recall papers could be sent to the central NOMS unit in London and that they could be held there pending further direction. The evidence from London was that this would never happen and all recall requests are processed according to their urgency. Should all probation staff be reminded of what the correct process is?
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Lack of direct communication between offender managers and hospital clinicians before recall decisions
Wider context from the report “(1) Before the recall paperwork was issued there was no direct conversation between the local offender manager and the clinician responsible for Mr Groombridge’s care in hospital. Should it not be policy for such a discussion to take place in any case where an offender is in hospital (be it for physical or mental reasons) before the recall is issued?
” Open source report
Concerns raised 3 Delays in summoning ambulances after emergency medical codes are broadcast View source Delays and lack of clarity in control-room responses to medical emergencies View source Failure to use appropriate codes for medical emergencies 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
Sharon Louise Suki Butcher · 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
Sharon Louise Suki Butcher died of natural causes, with the inquest recording ischaemic heart disease, coronary artery atheroma, diabetes mellitus and cirrhosis of the liver. The report raised concerns about a 10-minute delay in calling an ambulance after an emergency medical code was broadcast, failure to follow the prison’s local protocol, and recurring lack of clarity in responding to medical emergencies.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Delays in summoning ambulances after emergency medical codes are broadcast
Wider context from the report “The PPO report highlights an issue relating to the delay in calling for an ambulance as soon as an emergency medical code was broadcast . There was a 10 minute delay and the prisons local protocol for summoning an ambulance was not followed . There have been a series of similar failings in dealing with medical emergencies of HMP Frankland and HMP Durham with either staff using wrong or inappropriate codes, or there being delays in the control room and this recurring issue of lack of clarity in response to a medical emergency could well lead to a fatality in the future.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Delays and lack of clarity in control-room responses to medical emergencies
Wider context from the report “The PPO report highlights an issue relating to the delay in calling for an ambulance as soon as an emergency medical code was broadcast. There was a 10 minute delay and the prisons local protocol for summoning an ambulance was not followed. There have been a series of similar failings in dealing with medical emergencies of HMP Frankland and HMP Durham with either staff using wrong or inappropriate codes, or there being delays in the control room and this recurring issue of lack of clarity in response to a medical emergency could well lead to a fatality in the future.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 codes for medical emergencies
Wider context from the report “The PPO report highlights an issue relating to the delay in calling for an ambulance as soon as an emergency medical code was broadcast. There was a 10 minute delay and the prisons local protocol for summoning an ambulance was not followed. There have been a series of similar failings in dealing with medical emergencies of HMP Frankland and HMP Durham with either staff using wrong or inappropriate codes , or there being delays in the control room and this recurring issue of lack of clarity in response to a medical emergency could well lead to a fatality in the future.
” Open source report
Concerns raised 4 Lack of defibrillator-use familiarisation for prison officers and staff with direct access to prisoners View source Limited availability of healthcare staff beyond 7am–6.30pm View source Lack of basic first aid training for prison officers and staff with direct access to prisoners View source Lack of CPR training for prison officers and staff with direct access to prisoners 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
Keith John MURPHY · 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
Keith John Murphy became physically ill in prison after using SPICE and was later found on his cell floor, where he was pronounced dead on 18 July 2013. The report raises concerns about basic first aid, CPR and defibrillator training for prison staff, and the availability of Healthcare staff outside the hours of 7am to 6.30pm.
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 defibrillator-use familiarisation for prison officers and staff with direct access to prisoners
Wider context from the report “1. Action is required to ensure that Prison Officers and Staff with direct access to prisoners have basic first aid training, CPR training and familiarisation with the use of a defibrillator.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Limited availability of healthcare staff beyond 7am–6.30pm
Wider context from the report “2. Action is required to ensure someone from Healthcare is available beyond the current arrangement of 7am – 6.30pm to provide an
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 basic first aid training for prison officers and staff with direct access to prisoners
Wider context from the report “1. Action is required to ensure that Prison Officers and Staff with direct access to prisoners have basic first aid training , CPR training and familiarisation with the use of a defibrillator.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 CPR training for prison officers and staff with direct access to prisoners
Wider context from the report “1. Action is required to ensure that Prison Officers and Staff with direct access to prisoners have basic first aid training, CPR training and familiarisation with the use of a defibrillator.
” 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 wider staff instruction on CPR and defibrillator use during monthly prisoner-regime closedowns.
Verbatim wording from the response “This policy is being implemented at HMP Coldingley. In order to ensure that a trained member of staff is always available, all Custodial Managers (CMs) are being trained. At present, all but two of the CMs at the prison have been trained, and those two members of staff will be provided with training as soon as they return to duty. HMP Coldingley also uses a monthly closedown of the prisoner regime to provide opportunities for training for the wider staff group and this includes instruction on CPR and on the use of defibrillators.” Source location 2015-0120-Response-by-NOMS
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Train all Custodial Managers in first aid to ensure trained staff are always available.
Verbatim wording from the response “First Aid training for prison staff
PSI 01/2014 First Aid describes the process for ensuring effective provision of first aid that enables NOMS to discharge its duty of care to its employees, to prisoners and to visitors to our premises. Governors are required to ensure that at all times such a number of suitably trained first aiders as is sufficient and appropriate for the circumstances at their prison is available. A First Aid risks/needs assessment is undertaken by the local Health and Safety Advisor to determine the appropriate numbers. Governors must ensure that first aiders are trained to levels which are appropriate for the circumstances and hold a valid certificate of competence in either First Aid at Work (FAW) or Emergency First Aid at Work (EFAW).” Source location 2015-0120-Response-by-NOMS
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The prison population is not considered to require on-site healthcare staffing outside normal hours.
Verbatim wording from the response “The size (531) and nature of the population at the prison, which is composed of prisoners who have been assessed by staff in other prisons as suitable to be accommodated at HMP Coldingley, is not believed to require the provision of on-site healthcare staffing out of hours. A recent Health Needs Assessment, commissioned through the NHS England South East Health and Justice commissioning team, confirms that the existing healthcare arrangements meet the needs of the prisoner population at the establishment.” Source location 2015-0120-Response-by-NOMS
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing out-of-hours healthcare arrangements are considered sufficient to meet the needs of the prison population.
Verbatim wording from the response “needs of the prisoner as appropriate. This arrangement is considered to be equivalent to what is available in the community. Where prisoners are perceived to require access to emergency and lifesaving care the local Ambulance Trust (South East Coast Ambulance NHS) is called for an emergency response.” Source location 2015-0120-Response-by-NOMS
Open published response
Concerns raised 7 Failure to comprehensively assess suicide and self-harm risk using documented risk factors and information View source Availability of removable plastic bin liners that can be used for suicide View source Lack of a national pro forma for ACCT opening and decision-making View source Allowing cell door keys to be carried around the neck on tied shoelaces View source Failure of healthcare screening to identify s.136 detentions as an enhanced-risk indicator View source Failure to use trigger-date information to prompt risk reassessment for prisoners outside the ACCT process View source Failure to retrofit cell doors with anti-ligature strips 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
Stuart Megginson BAUMBER · 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
Stuart Megginson BAUMBER died by hanging in his cell at HMP Peterborough between 22:30 on 14 November 2013 and 04:10 on 15 November 2013, after being remanded in custody for arson. The jury found that occasions existed when the ACCT process should have been initiated and that inadequate understanding and training contributed to this not happening. The report also raised concerns about ligature points on cell doors, healthcare screening that did not mention section 136 detentions, and items available to prisoners that could facilitate suicide.
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 comprehensively assess suicide and self-harm risk using documented risk factors and information
Wider context from the report “8. There appears to be on occasions an over reliance on assessment of current risk as emphasised in the QTLB of 2012 by considering demeanour and presentation at the reception stage. The PPO bulletin of March 2015 highlights deficiencies in this approach. There are known risk factors for suicide and self-harm and active identification of relevant risk factors from documentation and information (e.g. SASH forms and PERs and medical records and an EME report) should be fully considered and balanced against apparent mood so that there is a comprehensive risk assessment.. A pro forma document could record what factors and information have been considered and the reasons for the 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 Availability of removable plastic bin liners that can be used for suicide
Wider context from the report “13. In addition, the deceased referred to experimentation by suffocation in his diary by putting a plastic bag over his head and some cells are known to have plastic removable bin liners which can be used as a means to take life .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Lack of a national pro forma for ACCT opening and decision-making
Wider context from the report “7. PSI 64/2011 and the Quick Time Learning Bulletin (issue 12 august 2012) which clarified opening an ACCT was the subject of much scrutiny. There seems to be no national pro forma document to guide staff through the process and document the decision making . By contrast, the Act 2 Care risk assessment in the Scottish prison system does provide a structured approach. A pro forma regime would have the advantage of providing an audit trail and can be reviewed for training purposes if shortcomings emerge.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Allowing cell door keys to be carried around the neck on tied shoelaces
Wider context from the report “12. Some prisoners at HMP Peterborough are allowed to carry their cell door key which is placed on shoelaces tied together and placed around the neck of the prisoner which clearly creates a self-made ligature for those who may be at risk.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure of healthcare screening to identify s.136 detentions as an enhanced-risk indicator
Wider context from the report “11. The healthcare screening which is a question and answer discussion based on specifically designed questions is prescriptive. It makes no mention of s.136 detentions which would be a clear indicator of enhanced risk and the deceased had two such detentions.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 trigger-date information to prompt risk reassessment for prisoners outside the ACCT process
Wider context from the report “9. It is known that a prisoners risk of self-harm and/or suicide may increase in certain circumstances. This applied to the deceased in this inquest. HMP Gartree have identified measures to identify potential triggers and there has been developed a database on trigger dates but only for those who are or have been subject to an ACCT . This could be refined to deal with re assessment of risk for many prisoners if key factors exist . (See Equality and Human Rights Commission paper in 2015 on Preventing Deaths in detention of adults with Mental Health Conditions). Again, the PPO bulletin of March 2015 highlighted increased vulnerability where a restraining order was made and this could be input into a database to prompt a review of risk.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison and Probation Service; that does not assign responsibility.
PFD Monitor interpretation Failure to retrofit cell doors with anti-ligature strips
Wider context from the report “3. However, whilst the current specification for cell door design now incorporates an anti-ligature strip, there is no retrofit programme in operation and thus, there are significant numbers of cell doors that do not meet the current standard .
” Open source report
Concerns raised 5 Lack of a computer-driven system to flag prescription non-attendance View source Lack of a specific policy for prisoners requiring 24-hour medical observation where constant medical supervision is unavailable View source Lack of a computer-driven system to flag lapsed prescriptions View source Distance and waiting times inhibiting prisoner attendance at the medical centre View source Failure of welfare checks to ascertain death View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Jason Edward Lawson · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Jason Edward Lawson, who had epilepsy and schizophrenia, was found dead in his prison cell at HMP Stocken on 17 March 2013; the time of death was uncertain but likely late on 16 March or early on 17 March. Concerns included welfare checks that did not establish that he had died, systems that did not reliably identify medication non-attendance or lapsed prescriptions, access delays to healthcare, and the absence of a specific policy for 24-hour medical observation where constant medical supervision was unavailable.
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 computer-driven system to flag prescription non-attendance
Wider context from the report “3. The current system relies on healthcare staff/pharmacy staff recognising that prisoners have not attended to collect their prescription , without having a computer driven system to flag up non-attendance .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 specific policy for prisoners requiring 24-hour medical observation where constant medical supervision is unavailable
Wider context from the report “5. There is no specific policy to deal with the situation where a prisoner needs 24 hour observation from medical staff where the prison is not equipped for constant medical 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 Lack of a computer-driven system to flag lapsed prescriptions
Wider context from the report “4. The current system relies on healthcare staff/pharmacy staff recognising that prescriptions have lapsed without having a computer driven system to flag it 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 Distance and waiting times inhibiting prisoner attendance at the medical centre
Wider context from the report “2. On some wings there is still some distance to walk to the medical centre and the time to wait mitigates against prisoners bothering to do attend .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from 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 welfare checks to ascertain death
Wider context from the report “1. The welfare check did not ascertain that he had died . He was certainly dead at the time of the check at 7.30am and 8.20am on the 17th March.
” Open source report
Concerns raised 2 Inadequacy of the Prisoner Escort Record View source Unavailability of System 1 medical records in specified reception units 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 Derek Stabler · 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 Derek Stabler was found hanging in a cell at HMP Lincoln on 4 March 2013 and died in Lincoln County Hospital on 6 March 2013. The substantive concerns were the need to review and redesign the Prisoner Escort Record and to ensure medical records were available at HMP North Sea Camp and HMP Lincoln.
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 Inadequacy of the Prisoner Escort Record
Wider context from the report “(i) That there is a need for the Prisoner Escort Record to be reviewed and redesigned
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation 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 System 1 medical records in specified reception units
Wider context from the report “(II) The requirements for System 1 (Medical Records) to be made available in Reception at HMP North Sea Camp and in The Care and Reception Unit at HMP Lincoln
” Open source report
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