HM Prison Service

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First report 2 Dec 2013•Latest report 7 Jun 2023

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports: 18
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

Concerns and recipient responses

Statements from HM Prison Service linked to the concerns in each report. Select any concern, action or position to view the source wording.

7 Jun2023
Lancashire and Blackburn with Darwen
Concerns raised1
1. Lack of available mouth protection for resuscitation
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Anthony George Smith · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Anthony George Smith was found hanging in his cell at HMP Preston on 4 May 2022 while suffering an acute relapse of schizophrenia, and officers commenced resuscitation. The report raised concerns that mouth-to-mouth resuscitation was performed without available mouth protection, creating risks of blood-borne virus transmission and potentially discouraging rescue breaths, and noted the need for readily accessible protection masks.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison Service; that does not assign responsibility.
PFD Monitor interpretation
Lack of available mouth protection for resuscitation
Wider context from the report
“(1) An officer attempting resuscitation carried out mouth to mouth resuscitation without the safeguard of mouth protection which was not available in the prison at the time. Mr Smith was a regular drug user who on occasions injected drugs. Performing mouth to mouth resuscitation carried with it the risk of transmission of blood born viruses with possible fatal consequences. (2) The lack of available protection not only carried with it a risk to those who performed resuscitation but potentially also to the person suffering a cardiac arrest in that without protection the would-be resuscitator might decline to provide rescue breaths ”
Open source report
19 Jul2022
Bedfordshire and Luton
Concerns raised1
1. Failure to design out injury and ligature points from prison cells
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Ezra Mathew TAMIEM · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Ezra Mathew Tamiem was detained at HMP Bedford and held in the healthcare wing because of concerns about his mental state and suicide risk. He was found hanging in his cell on 15 July 2020 and was confirmed deceased by paramedics. The concerns included a ligature point in the cell and a serious failure of the required observation procedure, with only two of five recorded observations performed.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison Service; that does not assign responsibility.
PFD Monitor interpretation
Failure to design out injury and ligature points from prison cells
Wider context from the report
“Mr Tamiem was housed in a cell on the healthcare wing. ████████ Head of Safety at HMP Bedford told the court that was for both security ████████ ████████ gave evidence that this device was in operation throughout the prison except in the refurbished cells and except in the “safer cell”. The safer cell did not have this ligature point. Safer cells are cells with injury and ligature points designed out. ████████ hanged himself and died as a result. ████████ told the court that there were no plans to remedy this and so the risk remains. ”
Open source report
22 Jan2022
Lancashire and Blackburn with Darwen
Concerns raised1
1. Lack of effective communication between healthcare personnel at medical emergencies and prison or ambulance control
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Thomas Mark Anthony Moffett · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Thomas Mark Anthony Moffett had probably suffered from diarrhoea and vomiting for up to three weeks before dying from natural causes following a cardiac arrest due to metabolic acidosis. Failures included an unlabelled blood sample, omission of an ECG, and inadequate communication of the patient’s condition and emergency level to ambulance control. The report raised concerns about communication arrangements between healthcare staff, prison control rooms and ambulance control, including the possibility of a wider national problem.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison Service; that does not assign responsibility.
PFD Monitor interpretation
Lack of effective communication between healthcare personnel at medical emergencies and prison or ambulance control
Wider context from the report
“(1) The evidence disclosed the need for healthcare and the prison to devise a better means of communication between healthcare personnel at the scene of a medical emergency and the prison control room / ambulance control (2) Similar communication difficulties have already been reported in relation to the inquest into the death of Martin Brown who died at HMIP Lancaster Farms and the Prison and Probation Ombudsman has highlighted a delay in the provision of essential information to Ambulance Control in the case of ████████ who died on 9th December 2020 at HMP Garth (3) The fact that communication difficulties have arisen between healthcare and the ambulance service in three recent cases involving prisons in Lancashire may indicate a potentially national problem ”
Open source report
12 Feb2021
Surrey
Concerns raised1
1. Failure of Approved Premises staff to be familiar with and apply Safe Working Practices Document guidance on resident safety
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Michael Dent-Jones · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Michael Dent-Jones was found deceased at St Catherine’s Priory on 14 July 2018 after an unintentional Tramadol overdose. The report identifies concerns that Approved Premises staff may not have been familiar with or applying guidance on the delivery and collection of residents’ prescribed medication and other resident-safety procedures.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison Service; that does not assign responsibility.
PFD Monitor interpretation
Failure of Approved Premises staff to be familiar with and apply Safe Working Practices Document guidance on resident safety
Wider context from the report
“Accordingly I am concerned that: - Staff at St Catherine’s Priory Approved Premises in Guildford, as well as staff in other Approved Premises nationally, may not be familiar with, or applying, the guidance set out in the Safe Working Practices Document in relation to the delivery/collection of residents’ prescribed medication, but also more generally in relation to the other policies and procedures pertaining to resident safety in that document. - Staff at St Catherine’s Priory Approved Premises in Guildford, as well as staff in other Approved Premises nationally, may not be familiar with, or applying, the guidance set out in the Safe Working Practices Document in relation to the delivery/collection of residents’ prescribed medication, but also more generally in relation to the other policies and procedures pertaining to resident safety in that document. ”
Open source report
10 Feb2021
Inner South London
Concerns raised3
1. Failure of the prisoner arrival form to sufficiently highlight self-harm and suicide risk to wing staff
2. Lack of robust management audit of nightly roll checks
3. Failure of the prisoner arrival form to provide a clear self-harm and suicide risk assessment and response pathway
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Jason O’Rourke · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Jason O’Rourke died by suicide in his cell at HMP Belmarsh after hanging himself with a bedsheet ligature between 7.28 pm on 1 April 2019 and 9.33 am on 2 April 2019. The jury identified possible contributing factors including inadequate follow-up of his mental health, insufficient sharing and understanding of information about his mental health and self-harm history, and inadequate safety intervention meetings. The report also raised concerns about unclear self-harm and suicide risk assessments on arrival and the lack of robust auditing of nightly roll checks.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison Service; that does not assign responsibility.
PFD Monitor interpretation
Failure of the prisoner arrival form to sufficiently highlight self-harm and suicide risk to wing staff
Wider context from the report
“(1) The ‘immediate needs’ form completed for prisoners on arrival at HMP Belmarsh does not facilitate a clear assessment of any risk of self-harm or suicide and the actions to be taken if such a risk is identified. The form poses a question: “Is there any specific concerns re self-harm or suicide?” and then gives the guidance “if yes, amend care plan”. However, this guidance is only effective for those prisoners who already have a care plan, meaning those who are already on an Open Assessment, Care in Custody and Teamwork (‘ACCT’) plan. The action to be taken for those prisoners where specific concerns regarding self-harm or suicide are identified, but who do not already have a care plan, is unclear from the form. It is also unclear how the above question interacts with further questions below it which address any past ACCTs/F2052SHs, the level of support available to the prisoner and the answer the prisoner gives to the question “Do you feel suicidal now?” Accordingly, this form does not sufficiently highlight prisoners who are in fact suicidal, or where there are concerns about their risk of self-harm or suicidal, to those on the wing. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison Service; that does not assign responsibility.
PFD Monitor interpretation
Lack of robust management audit of nightly roll checks
Wider context from the report
“(2) The nightly roll checks at HMP Belmarsh are due to be carried out by a single member of Operational Support Grade (OSG) staff at 9.00 pm and 6.00 am. Their stated purpose is to check for escape or death among the prisoners. On handing over to the morning staff, the OSG signs paperwork indicating that the roll checks have been completed. There is no robust system by which the prison management audit this process. This means that the prison management can be under the impression that the checks have been carried out, when they have not been, as occurred here. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison Service; that does not assign responsibility.
PFD Monitor interpretation
Failure of the prisoner arrival form to provide a clear self-harm and suicide risk assessment and response pathway
Wider context from the report
“(1) The ‘immediate needs’ form completed for prisoners on arrival at HMP Belmarsh does not facilitate a clear assessment of any risk of self-harm or suicide and the actions to be taken if such a risk is identified. The form poses a question: “Is there any specific concerns re self-harm or suicide?” and then gives the guidance “if yes, amend care plan”. However, this guidance is only effective for those prisoners who already have a care plan, meaning those who are already on an Open Assessment, Care in Custody and Teamwork (‘ACCT’) plan. The action to be taken for those prisoners where specific concerns regarding self-harm or suicide are identified, but who do not already have a care plan, is unclear from the form. It is also unclear how the above question interacts with further questions below it which address any past ACCTs/F2052SHs, the level of support available to the prisoner and the answer the prisoner gives to the question “Do you feel suicidal now?” Accordingly, this form does not sufficiently highlight prisoners who are in fact suicidal, or where there are concerns about their risk of self-harm or suicidal, to those on the wing. ”
Open source report
20 Dec2019
Manchester City
Concerns raised21
1. Insufficient availability of safer cells and CCTV-monitored cells
2. Absence of timely, full and accurate clinical record keeping
3. Lack of written rationale for self-harm and suicide risk assessments
1. Inappropriate minimisation of prisoners’ illness or vulnerability during transfer decisions
2. Inconsistent use of interpretation services during healthcare interviews and ACCT reviews
3. Overreliance on prisoners’ denials and tick-box recording in suicide and self-harm risk assessment
4. Inadequate ACCT review during moves from safer cells to ordinary cells
5. Failure to maintain auditable cross-shift handover of relevant information
6. Failure to provide coordinated interpreted communication about prisoner transfers
7. Failure of prison staff to separately record self-harm and suicide risk information
8. Observation regimes failing to account for predictable observation patterns
9. Failure to review ACCT risk information and escalate concerns on arrival
10. Failure to record attendees at healthcare interviews involving prison discipline staff
11. Failure of staff to understand transfer rationale and destination suitability
12. Failure to review and record relevant developing medical history before clinical interactions
13. Failure to ensure prisoners understand transfer reasons and destination regimes
14. Failure to identify participating healthcare staff and verify completeness of System One records
15. Failure to undertake holistic and updated self-harm or suicide risk assessment
16. Failure to hand over relevant ACCT risk information to receiving colleagues
17. Failure of receiving-wing staff to attend final ACCT case reviews before transfer
18. Failure to make appropriate documentary records for ACCT transfers
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Tomasz Nowosad · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Tomasz Nowosad was found hanging by a ligature in an ordinary, non-safe cell at HMP Manchester on 2 February 2017, shortly after being transferred from the healthcare centre. The report identifies concerns about risk assessment, including reliance on his denials of suicidal thoughts, incomplete and delayed clinical records, inconsistent use of interpretation services, and his transfer to an ordinary wing despite expressed fears and mental health risks. The inquest jury concluded that the death was suicide contributed to by neglect.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison Service; that does not assign responsibility.
PFD Monitor interpretation
Insufficient availability of safer cells and CCTV-monitored cells
Wider context from the report
“5.14 It is suggested that HMPS should consider increasing the number of Safer cells throughout the whole of the prison and also having more CCTV monitored cells. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison Service; that does not assign responsibility.
PFD Monitor interpretation
Absence of timely, full and accurate clinical record keeping
Wider context from the report
“5 5 It is suggested that there was an absence of timely, full and accurate clinical record keeping by members of GMMH mental health staff (whether they be healthcare assistants, nurses or doctors) This is a professional requirement under GMC Good Practice and the NMC code of conduct It is suggested that steps are taken to ensure this is completed in all cases and appropriate audits undertaken to check on this. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison Service; that does not assign responsibility.
PFD Monitor interpretation
Lack of written rationale for self-harm and suicide risk assessments
Wider context from the report
“5 3 It is suggested that whenever an assessment of risk of self-harm or suicide is undertaken there is a written record made of the factors or issues involved in this or what weight or consideration was given to them and how the risk assessment was arrived at It is suggested that it would be appropriate for GMMH and HMPS to ensure that this is introduced ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison Service; that does not assign responsibility.
PFD Monitor interpretation
Inappropriate minimisation of prisoners’ illness or vulnerability during transfer decisions
Wider context from the report
“5 16 It is suggested that it is not appropriate to indicate to a patient prisoner that they are not so ill or vulnerable as others in considering a move out of the HCC because that may influence their cooperation and disclosure of their symptoms and presentation It is suggested that guidance is issued to GMMH staff about this ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison Service; that does not assign responsibility.
PFD Monitor interpretation
Inconsistent use of interpretation services during healthcare interviews and ACCT reviews
Wider context from the report
“5 4 It appears that there was no consistent use of the language line interpretation service by HMPS or GMMH staff, and it is suggested that wherever an identified need for the use of this service is recognised it should be used on all healthcare interviews as well as at ACCT reviews While some prisoners may speak some, little or virtually no English, it is essential that every effort is made to ensure that they can understand, so far as it possible, the issues being raised and discussed with them. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison Service; that does not assign responsibility.
PFD Monitor interpretation
Overreliance on prisoners’ denials and tick-box recording in suicide and self-harm risk assessment
Wider context from the report
“5 1 The context of this case has to be seen in the light of the fact that in 2019 two self-inflicted deaths happened at HMP Manchester There were four in 2018 and my records indicate that there have been 29 from the beginning of 2006 up to date In view of the evidential issues highlighted above it is suggested that there has been a repeated theme in the majority of these cases that there was an over reliance and emphasis on the assumptions made by a prisoner that they “had no thoughts of self-harm or suicide” This is often simply recorded in ACCT reviews by ticking boxes on the review document. Whilst it is appropriate for this issue to be addressed whenever a prison is on an ACCT either by healthcare staff or at ACCT reviews because in many cases prisoners still go on to harm themselves or commit suicide It should not be regarded as definitive This was recognised and recorded in the latest PPO Investigation Report relating to a death that occurred on 5 April 2019 This was specifically referred to in paragraph 26 of the report which said “In previous investigation into self-inflicted deaths at Manchester, we identified weaknesses in the risk assessment of prisoners at risk of suicide and self-harm We found in particular that staff placed too much emphasis on prisoner’s presentation and did not give sufficient consideration to their risk factors” ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison Service; that does not assign responsibility.
PFD Monitor interpretation
Inadequate ACCT review during moves from safer cells to ordinary cells
Wider context from the report
“5 13 It is suggested that since that the overwhelming majority of prisoners who kill themselves do so by ligatures particular care should be taken when prisoner who is on an ACCT is moved from a safer cell to an ordinary cell and their ACCT should be carefully reviewed and the number, type and frequency of observations Prisoner can quickly get used to the regularity of observations and undertake self-harming or suicidal behaviour when they think they will not be seen or have contact from HMPS or GMMH staff ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison Service; that does not assign responsibility.
PFD Monitor interpretation
Failure to maintain auditable cross-shift handover of relevant information
Wider context from the report
“5 11 It is suggested that there should be an auditable process of ensuring that all appropriate information is handed over between different shifts of GMMH and HMPS staff so that there is a continuity and consistency of available information ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison Service; that does not assign responsibility.
PFD Monitor interpretation
Failure to provide coordinated interpreted communication about prisoner transfers
Wider context from the report
“5 15 It is suggested that it is not appropriate for GMMH clinical or Nursing Staff to put the onus or responsibility on a prisoner to interact with HMPS staff to try and understand why they may be moving from one location to another without both being present and the language line service used to try and ensure no miscommunication and that appropriate written guidance should be given to all staff ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison Service; that does not assign responsibility.
PFD Monitor interpretation
Failure of prison staff to separately record self-harm and suicide risk information
Wider context from the report
“5 7 It is suggested that whenever there is a healthcare interview and a member of prison discipline staff is present, records should be kept by GMMH and HMPS of who was there, but also HMPS staff should record separately within their records evidence and information relevant to the risk of self-harm or suicide ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison Service; that does not assign responsibility.
PFD Monitor interpretation
Observation regimes failing to account for predictable observation patterns
Wider context from the report
“5 13 It is suggested that since that the overwhelming majority of prisoners who kill themselves do so by ligatures particular care should be taken when prisoner who is on an ACCT is moved from a safer cell to an ordinary cell and their ACCT should be carefully reviewed and the number, type and frequency of observations Prisoner can quickly get used to the regularity of observations and undertake self-harming or suicidal behaviour when they think they will not be seen or have contact from HMPS or GMMH staff ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison Service; that does not assign responsibility.
PFD Monitor interpretation
Failure to review ACCT risk information and escalate concerns on arrival
Wider context from the report
“5 9 It is suggested that receiving HMPS staff should ensure that they read and consider the ACCT file with particular emphasis on the assessment of risk of self-harm and suicide and how it has been managed to date and whether or not that needs to be reviewed on arrival Any concerns should be escalated ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison Service; that does not assign responsibility.
PFD Monitor interpretation
Failure to record attendees at healthcare interviews involving prison discipline staff
Wider context from the report
“5 7 It is suggested that whenever there is a healthcare interview and a member of prison discipline staff is present, records should be kept by GMMH and HMPS of who was there, but also HMPS staff should record separately within their records evidence and information relevant to the risk of self-harm or suicide ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison Service; that does not assign responsibility.
PFD Monitor interpretation
Failure of staff to understand transfer rationale and destination suitability
Wider context from the report
“5 10 It is suggested that GMMH and HMPS staff should ensure as is far as is reasonably possible that the patient prisoner has a real understanding and comprehension of the reasons for transfer and the regime to which they are going, particularly if they have been moved from the HCC when they occupied a safer cell but were going to an ordinary cell with a number of ligature points The staff themselves have to have a clear understanding of the reasons for transfer and what the new wing regime or locations means for the prisoner and whether or not it is appropriate Records should be kept of the reasoning and justification ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison Service; that does not assign responsibility.
PFD Monitor interpretation
Failure to review and record relevant developing medical history before clinical interactions
Wider context from the report
“5 12 It is suggested that GMMH staff should ensure that when they have any clinical interactions with patient prisoners they familiarise themselves with all the developing relevant medical history including recent events and record what they have reviewed or considered ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison Service; that does not assign responsibility.
PFD Monitor interpretation
Failure to ensure prisoners understand transfer reasons and destination regimes
Wider context from the report
“5 10 It is suggested that GMMH and HMPS staff should ensure as is far as is reasonably possible that the patient prisoner has a real understanding and comprehension of the reasons for transfer and the regime to which they are going, particularly if they have been moved from the HCC when they occupied a safer cell but were going to an ordinary cell with a number of ligature points The staff themselves have to have a clear understanding of the reasons for transfer and what the new wing regime or locations means for the prisoner and whether or not it is appropriate Records should be kept of the reasoning and justification ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison Service; that does not assign responsibility.
PFD Monitor interpretation
Failure to identify participating healthcare staff and verify completeness of System One records
Wider context from the report
“5 6 It is suggested that whenever there is a healthcare interaction with a patient prisoner and more than one healthcare member of staff is present, their identities should be recorded and all clinically relevant information is included within the System One records and checked between those present as being full and complete ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison Service; that does not assign responsibility.
PFD Monitor interpretation
Failure to undertake holistic and updated self-harm or suicide risk assessment
Wider context from the report
“5 2 PSI-64/2011 recognises that there are a number of potential triggers to self-harming behaviour or suicide All staff should be alert to the increased risk of self-harm or suicide posed by prisoners with these risk factors and should act appropriately to address any concerns, including opening an ACCT if necessary However, it is suggested that the list of factors is not exhaustive and everything needs to be considered in light of the overall picture This will usually involve discipline staff and health care staff It is suggested that thereafter, particularly if the prisoner is moved to the HCC, considering all the risk factors and the changing position taking into account the previous recorded history of the prisoner from both a health care and general prison service records This is especially so when ACCTs are being reviewed and a prisoner is being discharged from the ACCT or moved out of the limited number of safer cells available in the prison There has to be consideration of the overall or ‘big picture’ with regards to the risks that the prisoner poses ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison Service; that does not assign responsibility.
PFD Monitor interpretation
Failure to hand over relevant ACCT risk information to receiving colleagues
Wider context from the report
“5 8 It is suggested that whenever there is a decision made to move a prisoner who is subject to an ACCT from the HCC to another location in the prison, prison staff of the receiving wing should ensure that they attend any final case reviews prior to discharge so that they are familiar with the relevant history and risks that the patient prisoner presents, make appropriate documentary records and ensure that relevant information is handed over to colleagues ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison Service; that does not assign responsibility.
PFD Monitor interpretation
Failure of receiving-wing staff to attend final ACCT case reviews before transfer
Wider context from the report
“5 8 It is suggested that whenever there is a decision made to move a prisoner who is subject to an ACCT from the HCC to another location in the prison, prison staff of the receiving wing should ensure that they attend any final case reviews prior to discharge so that they are familiar with the relevant history and risks that the patient prisoner presents, make appropriate documentary records and ensure that relevant information is handed over to colleagues ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison Service; that does not assign responsibility.
PFD Monitor interpretation
Failure to make appropriate documentary records for ACCT transfers
Wider context from the report
“5 8 It is suggested that whenever there is a decision made to move a prisoner who is subject to an ACCT from the HCC to another location in the prison, prison staff of the receiving wing should ensure that they attend any final case reviews prior to discharge so that they are familiar with the relevant history and risks that the patient prisoner presents, make appropriate documentary records and ensure that relevant information is handed over to colleagues ”
Open source report
26 Nov2019
Hampshire
Concerns raised2
1. Failure to identify increased self-harm risk in prisoners due in Court the following morning
2. Failure to notify night staff of prisoners due in Court the following morning
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Trevor Albert Oakley · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Trevor Albert Oakley was found hanging from a bedsheet ligature in his prison cell on 22 October 2018, shortly before he was due to start his trial. The inquest concluded that his death was suicide. The principal concern was that night staff were not immediately informed which prisoners were due in court the following morning, meaning increased self-harm risks might not be identified.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison Service; that does not assign responsibility.
PFD Monitor interpretation
Failure to identify increased self-harm risk in prisoners due in Court the following morning
Wider context from the report
“(1) I was told that the Courts will supply the Prison with a list of prisoners who are required for trial the following day, (“the List”). The List is circulated within the prison by the OMU (Offender Management Unit) and the relevant staff should receive the List to enable them to know which particular prisoners need to be unlocked for Court attendances the following day. I was told that the Night Orderly Officer will brief the night shift officers on the wings as to what is due to be happening over the course of the night shift, but it was the evidence of more than one Prison Officer on duty that there was no notification of the prisoners due in Court the next morning. The stance adopted within the prison appeared to be that the information was available if a Prison Officer wanted to go and look for it within the system. (2) I am concerned that within the Prison it is not immediately apparent to the night staff who is due in Court the following morning from this, it flows, that any increased risk of self-harm by such prisoner(s) is not identified. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison Service; that does not assign responsibility.
PFD Monitor interpretation
Failure to notify night staff of prisoners due in Court the following morning
Wider context from the report
“(1) I was told that the Courts will supply the Prison with a list of prisoners who are required for trial the following day, (“the List”). The List is circulated within the prison by the OMU (Offender Management Unit) and the relevant staff should receive the List to enable them to know which particular prisoners need to be unlocked for Court attendances the following day. I was told that the Night Orderly Officer will brief the night shift officers on the wings as to what is due to be happening over the course of the night shift, but it was the evidence of more than one Prison Officer on duty that there was no notification of the prisoners due in Court the next morning. The stance adopted within the prison appeared to be that the information was available if a Prison Officer wanted to go and look for it within the system. (2) I am concerned that within the Prison it is not immediately apparent to the night staff who is due in Court the following morning from this, it flows, that any increased risk of self-harm by such prisoner(s) is not identified. ”
Open source report
27 Feb2019
Worcestershire
Concerns raised5
1. Failure to operate the ACCT process in accordance with national and local policies
2. Inadequate ACCT documentation
3. Inconsistent or undocumented communication between staff involved in ACCT decisions
1. Failure to rectify recurring ACCT process failings
2. Absence or unclear identification of health care department input to ACCT reviews
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Kelvin Sean Speakman · 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

Kelvin Sean Speakman was a serving prisoner at HMP Hewell with a long history of mental ill-health and extensive self-harm, including multiple attempts to hang himself. Following an incident of self-ligaturing, he suffered a hypoxic brain injury and died in hospital on 9 May 2016. The report identified shortcomings in the operation and documentation of the ACCT process, including inadequate healthcare input and inconsistent communication between staff.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison Service; that does not assign responsibility.
PFD Monitor interpretation
Failure to operate the ACCT process in accordance with national and local policies
Wider context from the report
“(1) The evidence in the case disclosed that the ACCT process was not handled completely in accordance with national and local policies and in particular the standard of documentation was often inadequate. The input to ACCT reviews by the health care department was often absent or the content of such input was not clearly identified. Communication between various staff members was either not consistent or documented leading to a conclusion that staff members making decisions about Mr Speakman were not aware of the full picture of his presenting condition. Although the evidence suggested that more was being done for him than the documentation might suggest it was clear from the evidence that there were gaps in information and potentially in the actions being undertaken. This is not the 1st inquest into a death at HMP Hewell where these criticisms have been made (frequently commented upon in successive PPO reports). In this and earlier inquests the prison have accepted the recommendations made by the PPO to improve the operation of the ACCT process and have given assurances that "lessons have been learned". However this case has highlighted the fact that notwithstanding those assurances the same failings appear time and time again. Furthermore deaths at HMP Hewell subsequent to Mr Speakman's and which are due to be heard at inquest later this year demonstrate clearly that the same failings exist and are perpetuated. I consider that the entirety of the operation of the ACCT process within HMP Hewell is in need of urgent and radical overhaul for the protection of prisoners being looked after under its auspices. (2) (3) ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison Service; that does not assign responsibility.
PFD Monitor interpretation
Inadequate ACCT documentation
Wider context from the report
“(1) The evidence in the case disclosed that the ACCT process was not handled completely in accordance with national and local policies and in particular the standard of documentation was often inadequate. The input to ACCT reviews by the health care department was often absent or the content of such input was not clearly identified. Communication between various staff members was either not consistent or documented leading to a conclusion that staff members making decisions about Mr Speakman were not aware of the full picture of his presenting condition. Although the evidence suggested that more was being done for him than the documentation might suggest it was clear from the evidence that there were gaps in information and potentially in the actions being undertaken. This is not the 1st inquest into a death at HMP Hewell where these criticisms have been made (frequently commented upon in successive PPO reports). In this and earlier inquests the prison have accepted the recommendations made by the PPO to improve the operation of the ACCT process and have given assurances that "lessons have been learned". However this case has highlighted the fact that notwithstanding those assurances the same failings appear time and time again. Furthermore deaths at HMP Hewell subsequent to Mr Speakman's and which are due to be heard at inquest later this year demonstrate clearly that the same failings exist and are perpetuated. I consider that the entirety of the operation of the ACCT process within HMP Hewell is in need of urgent and radical overhaul for the protection of prisoners being looked after under its auspices. (2) (3) ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison Service; that does not assign responsibility.
PFD Monitor interpretation
Inconsistent or undocumented communication between staff involved in ACCT decisions
Wider context from the report
“(1) The evidence in the case disclosed that the ACCT process was not handled completely in accordance with national and local policies and in particular the standard of documentation was often inadequate. The input to ACCT reviews by the health care department was often absent or the content of such input was not clearly identified. Communication between various staff members was either not consistent or documented leading to a conclusion that staff members making decisions about Mr Speakman were not aware of the full picture of his presenting condition. Although the evidence suggested that more was being done for him than the documentation might suggest it was clear from the evidence that there were gaps in information and potentially in the actions being undertaken. This is not the 1st inquest into a death at HMP Hewell where these criticisms have been made (frequently commented upon in successive PPO reports). In this and earlier inquests the prison have accepted the recommendations made by the PPO to improve the operation of the ACCT process and have given assurances that "lessons have been learned". However this case has highlighted the fact that notwithstanding those assurances the same failings appear time and time again. Furthermore deaths at HMP Hewell subsequent to Mr Speakman's and which are due to be heard at inquest later this year demonstrate clearly that the same failings exist and are perpetuated. I consider that the entirety of the operation of the ACCT process within HMP Hewell is in need of urgent and radical overhaul for the protection of prisoners being looked after under its auspices. (2) (3) ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison Service; that does not assign responsibility.
PFD Monitor interpretation
Failure to rectify recurring ACCT process failings
Wider context from the report
“(1) The evidence in the case disclosed that the ACCT process was not handled completely in accordance with national and local policies and in particular the standard of documentation was often inadequate. The input to ACCT reviews by the health care department was often absent or the content of such input was not clearly identified. Communication between various staff members was either not consistent or documented leading to a conclusion that staff members making decisions about Mr Speakman were not aware of the full picture of his presenting condition. Although the evidence suggested that more was being done for him than the documentation might suggest it was clear from the evidence that there were gaps in information and potentially in the actions being undertaken. This is not the 1st inquest into a death at HMP Hewell where these criticisms have been made (frequently commented upon in successive PPO reports). In this and earlier inquests the prison have accepted the recommendations made by the PPO to improve the operation of the ACCT process and have given assurances that "lessons have been learned". However this case has highlighted the fact that notwithstanding those assurances the same failings appear time and time again. Furthermore deaths at HMP Hewell subsequent to Mr Speakman's and which are due to be heard at inquest later this year demonstrate clearly that the same failings exist and are perpetuated. I consider that the entirety of the operation of the ACCT process within HMP Hewell is in need of urgent and radical overhaul for the protection of prisoners being looked after under its auspices. (2) (3) ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison Service; that does not assign responsibility.
PFD Monitor interpretation
Absence or unclear identification of health care department input to ACCT reviews
Wider context from the report
“(1) The evidence in the case disclosed that the ACCT process was not handled completely in accordance with national and local policies and in particular the standard of documentation was often inadequate. The input to ACCT reviews by the health care department was often absent or the content of such input was not clearly identified. Communication between various staff members was either not consistent or documented leading to a conclusion that staff members making decisions about Mr Speakman were not aware of the full picture of his presenting condition. Although the evidence suggested that more was being done for him than the documentation might suggest it was clear from the evidence that there were gaps in information and potentially in the actions being undertaken. This is not the 1st inquest into a death at HMP Hewell where these criticisms have been made (frequently commented upon in successive PPO reports). In this and earlier inquests the prison have accepted the recommendations made by the PPO to improve the operation of the ACCT process and have given assurances that "lessons have been learned". However this case has highlighted the fact that notwithstanding those assurances the same failings appear time and time again. Furthermore deaths at HMP Hewell subsequent to Mr Speakman's and which are due to be heard at inquest later this year demonstrate clearly that the same failings exist and are perpetuated. I consider that the entirety of the operation of the ACCT process within HMP Hewell is in need of urgent and radical overhaul for the protection of prisoners being looked after under its auspices. (2) (3) ”
Open source report
2 Mar2018
West Yorkshire Eastern
Concerns raised1
1. Lack of suitable secure therapeutic environments for people with mental health problems in prison
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Emily Jayne Hartley · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Emily Jayne Hartley, a serving prisoner at HMP New Hall, was found suspended from a torn bed sheet in an out-of-bounds area during exercise on 23 April 2016; her death was confirmed at the scene. Concerns included serious deficiencies in the management, monitoring and recording of self-harm and suicide prevention procedures, weak information sharing and integrated planning, poor supervision, and the lack of a suitable secure therapeutic environment for people with significant mental health problems.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison Service; that does not assign responsibility.
PFD Monitor interpretation
Lack of suitable secure therapeutic environments for people with mental health problems in prison
Wider context from the report
“(1) It became apparent from the evidence of many Prison Officers and Healthcare Workers that Prison was not the appropriate environment for someone with Emily’s mental health problems. The emphasis should have been on treatment but within a secure environment which Prison, with the most well intentioned staff, cannot adequately provide. (2) Coincidentally ten years ago I heard an Inquest into the death of Petra Blankbsy, also at New Hall Prison. At the conclusion of this inquest I made a recommendation pursuant to what was then Rule 43 of the Coroner’s Rules 1984. I attach a copy of my Rule 43 recommendations which I repeat in every detail in respect of the death of Emily Jayne Hartley. Furthermore I state that a Prison is not the appropriate place to accommodate Emily and that there should be facilities, particularly in the Prison’s female estate, to provide a therapeutic yet secure environment with the emphasis being on treatment. I repeat ten years later that the Prison’s department and the Department of Health should conduct a collaborative exercise to achieve the provision of suitable, secure, therapeutic environments in order to treat those with mental health problems of the nature of those demonstrated by Petra Blanksby ten years ago and now Emily Jayne Hartley. I would refer you to a paper prepared by “Inquest” entitled Preventing the Deaths of Women in Prison and the Need for an Alternative Approach which was published in June 2013 and also a report by ████████ of a review of Women with Particular Vulnerabilities in the Criminal Justice System. ”
Open source report
15 Feb2018
Essex
Concerns raised7
1. Inadequate standard and accuracy of record keeping by disciplinary and healthcare staff
2. Inadequate communication between healthcare and disciplinary staff about the purpose of Intelligence Reports
3. Inadequate processes and systems for reducing access to illegal substances
1. Lack of an appropriate audit system
2. Lack of criteria and a system for Intelligence Reports
3. Inadequate referral processes to psychosocial services
4. Failure of healthcare staff to complete Intelligence Reports correctly
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Timothy John Shaw · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Timothy John Shaw, aged 34, was found collapsed in his prison cell on 28 February 2017 after apparent substance use and died in hospital on 2 March 2017. The report identified concerns about communication, intelligence reporting, access to illegal substances, referrals to psychosocial services, and record keeping.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison Service; that does not assign responsibility.
PFD Monitor interpretation
Inadequate standard and accuracy of record keeping by disciplinary and healthcare staff
Wider context from the report
“The standard and accuracy of record keeping by both disciplinary and Healthcare staff needs to be improved. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison Service; that does not assign responsibility.
PFD Monitor interpretation
Inadequate communication between healthcare and disciplinary staff about the purpose of Intelligence Reports
Wider context from the report
“Healthcare staff seemed unclear as to how to fill in an Intelligence Report. There needs to be better communication between Healthcare staff and disciplinary staff as to the purpose of an Intelligence Report. Some criteria need to be developed and a system in place. An appropriate audit system needs to be in place. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison Service; that does not assign responsibility.
PFD Monitor interpretation
Inadequate processes and systems for reducing access to illegal substances
Wider context from the report
“The processes and systems for reducing access to illegal substances need to be improved and tightened up ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison Service; that does not assign responsibility.
PFD Monitor interpretation
Lack of an appropriate audit system
Wider context from the report
“Healthcare staff seemed unclear as to how to fill in an Intelligence Report. There needs to be better communication between Healthcare staff and disciplinary staff as to the purpose of an Intelligence Report. Some criteria need to be developed and a system in place. An appropriate audit system needs to be in place. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison Service; that does not assign responsibility.
PFD Monitor interpretation
Lack of criteria and a system for Intelligence Reports
Wider context from the report
“Healthcare staff seemed unclear as to how to fill in an Intelligence Report. There needs to be better communication between Healthcare staff and disciplinary staff as to the purpose of an Intelligence Report. Some criteria need to be developed and a system in place. An appropriate audit system needs to be in place. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison Service; that does not assign responsibility.
PFD Monitor interpretation
Inadequate referral processes to psychosocial services
Wider context from the report
“The processes for referrals by both prisoners and staff to psychosocial services needs to be tightened up and improved. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison Service; that does not assign responsibility.
PFD Monitor interpretation
Failure of healthcare staff to complete Intelligence Reports correctly
Wider context from the report
“Healthcare staff seemed unclear as to how to fill in an Intelligence Report. There needs to be better communication between Healthcare staff and disciplinary staff as to the purpose of an Intelligence Report. Some criteria need to be developed and a system in place. An appropriate audit system needs to be in place. ”
Open source report
20 Dec2017
Essex
Concerns raised1
1. Lack of a reliable documentary system for communicating mental health referral information
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Craig David Royce · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Craig Royce, who had a history of mental health problems and epilepsy, was found hanging in his prison cell on 24 December 2016. The report identified concerns that a referral to mental health services following an incident of self-harm was not made and that there was no robust documentary system for communicating such referrals. The inquest jury also considered that his risk of self-harm or suicide was not properly reviewed with appropriate precautions taken.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison Service; that does not assign responsibility.
PFD Monitor interpretation
Lack of a reliable documentary system for communicating mental health referral information
Wider context from the report
“There is no form/template to deal with the situation of a prisoner who needs to be referred to the mental health service. Reliance upon the transfer of this vital information to Healthcare by means of a telephone conversation could be unreliable. A robust, simple documentary system is required for the communication of such important information, namely that a prisoner needs to be referred to mental health services for an assessment to be carried out by mental health services. This would be distinct from the TAG system which caters for a brief assessment to be relayed across. ”
Open source report
17 Feb2017
Essex
Concerns raised8
1. Failure of the admissions protocol to allow transfer of mentally disordered people from police custody
2. Failure to meaningfully involve families in the ACCT process
3. Insufficient resilience of psychiatric cover at Chelmsford prison
1. Failure to provide effective ACCT process training
2. Lack of a written record of the forensic pathway
3. Failure to formally record concerns raised by a prisoner’s family
4. Failure to communicate concerns raised by a prisoner’s family
5. Lack of clarity in the hospital transfer process
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Dean Gary Saunders · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Dean Gary Saunders was found unresponsive in his cell at HM Prison Chelmsford on 4 January 2016, and his death was confirmed as electrocution. The inquest identified serious failings in mental health assessment and care, the prison transfer pathway, ACCT assessments and observations, record-keeping and communication, clinical leadership, and family involvement.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison Service; that does not assign responsibility.
PFD Monitor interpretation
Failure of the admissions protocol to allow transfer of mentally disordered people from police custody
Wider context from the report
“1. FOR SEPT:- The admitted lacuna in the SEPT admissions protocol governing the transfer of mentally disordered people from police custody. The current admissions protocol does not allow for the transfer of any individual from police custody, irrespective of the criminal charges the individual is facing. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison Service; that does not assign responsibility.
PFD Monitor interpretation
Failure to meaningfully involve families in the ACCT process
Wider context from the report
“6. FOR NOMS:- The meaningful involvement of families in the ACCT process, including by ensuring the formal recording, and communication of concerns raised by a prisoner’s family. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison Service; that does not assign responsibility.
PFD Monitor interpretation
Insufficient resilience of psychiatric cover at Chelmsford prison
Wider context from the report
“5. FOR NHS ENGLAND:- The resilience of psychiatric cover at Chelmsford prison, which would need to be raised with NHS England who commission such services and decide on the budget. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison Service; that does not assign responsibility.
PFD Monitor interpretation
Failure to provide effective ACCT process training
Wider context from the report
“4. FOR NOMS:- Training regarding the ACCT process. In previous prison deaths and in response to previous PPO reports, promises have been made about training having been provided to staff yet the same mistakes are being repeated. Meaningful action in required in this regard. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison Service; that does not assign responsibility.
PFD Monitor interpretation
Lack of a written record of the forensic pathway
Wider context from the report
“2. FOR SEPT AND NHS ENGLAND:- The absence of a written record of the “best practice” forensic pathway referred to by ████████ in his evidence, and consideration of whether the transfer of individuals such as Dean to prison is indeed “best practice”, taking into account the consequent delay in transfer and the suitability of the prison environment for mentally disordered individuals. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison Service; that does not assign responsibility.
PFD Monitor interpretation
Failure to formally record concerns raised by a prisoner’s family
Wider context from the report
“6. FOR NOMS:- The meaningful involvement of families in the ACCT process, including by ensuring the formal recording, and communication of concerns raised by a prisoner’s family. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison Service; that does not assign responsibility.
PFD Monitor interpretation
Failure to communicate concerns raised by a prisoner’s family
Wider context from the report
“6. FOR NOMS:- The meaningful involvement of families in the ACCT process, including by ensuring the formal recording, and communication of concerns raised by a prisoner’s family. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison Service; that does not assign responsibility.
PFD Monitor interpretation
Lack of clarity in the hospital transfer process
Wider context from the report
“3. FOR CARE UK, NOMS, SEPT:- The lack of clarity regarding the hospital transfer process. The evidence at the inquest demonstrated that this is currently shrouded in confusion and contradiction (if the PSI and the NHS England “good practice” is compared). Given that rationalisation of the process is still a “work in progress”, the family consider that it should be given urgent consideration. ”
Open source report
30 Jan2017
County Durham and Darlington
Concerns raised2
1. Failure to recognise increased risk from persistently unusual behaviour
2. Failure to use appropriate language when describing situations for risk assessment
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Margaret Atkinson · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Margaret Atkinson, who had a long history of mental health illness and was in prison healthcare, was found unresponsive in her cell on 24 January 2016 after staff observed clothing around her neck and delayed entering the cell; she died in hospital on 2 February 2016. The jury found that staff should have entered earlier, and the report identified difficulties in describing such situations and assessing risk when unusual behaviour had become accepted as normal.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison Service; that does not assign responsibility.
PFD Monitor interpretation
Failure to recognise increased risk from persistently unusual behaviour
Wider context from the report
“(1) The case revealed issues and difficulties about how situations were described and the choice of appropriate language with the corresponding difficulties resulting therefrom in assessing risk. Furthermore, as there was unusual behaviour over an extended period of time there was an acceptance of such behaviour as being normal and would not be considered as illustrative of increased risk unless there was a significant departure from that already unusual (or bizarre behaviour as it was described in evidence). HMP Low Newton have issued interim guidance to endeavour to address the matter and G4S likewise. A copy of the G4S guidance is attached. This appears good, I believe it needs to be shared throughout the prisoner state generally and not just in the North East cluster of prisons where G4S provides healthcare. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison Service; that does not assign responsibility.
PFD Monitor interpretation
Failure to use appropriate language when describing situations for risk assessment
Wider context from the report
“(1) The case revealed issues and difficulties about how situations were described and the choice of appropriate language with the corresponding difficulties resulting therefrom in assessing risk. Furthermore, as there was unusual behaviour over an extended period of time there was an acceptance of such behaviour as being normal and would not be considered as illustrative of increased risk unless there was a significant departure from that already unusual (or bizarre behaviour as it was described in evidence). HMP Low Newton have issued interim guidance to endeavour to address the matter and G4S likewise. A copy of the G4S guidance is attached. This appears good, I believe it needs to be shared throughout the prisoner state generally and not just in the North East cluster of prisons where G4S provides healthcare. ”
Open source report
4 Oct2016
Central Hampshire
Concerns raised6
1. Failure to implement ACCT plans in accordance with national policy
2. Inadequate observations under ACCT plans
3. Failure to train Listeners to pass information about imminent suicide risk to prison staff
1. Failure to make Case Notes for all ACCT plans
2. Failure of the Listener Scheme protocol to specify an exception to confidentiality for imminent suicide risk
3. Limitations of the NOMIS database in recording details of closed ACCT plans
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Haydn James Burton · 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

Haydn James Burton, a prisoner at HMP Winchester, was found suspended from a ligature point in his cell on 15 July 2015 and died in hospital on 18 July 2015 from the delayed effects of ligature suspension. The concerns included inadequate implementation of ACCT plans and observations, uncertainty about confidentiality rules in the Prison Listener scheme, and limitations in recording and communicating information about closed ACCT plans.

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 Service; that does not assign responsibility.
PFD Monitor interpretation
Failure to implement ACCT plans in accordance with national policy
Wider context from the report
“(1) The evidence in this case indicated that prison staff at Winchester Prison are not implementing ACCT plans in accordance with national policy notwithstanding the training they have received and in particular the observations conducted are inadequate. I therefore consider that the process and future training needs to be reviewed ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison Service; that does not assign responsibility.
PFD Monitor interpretation
Inadequate observations under ACCT plans
Wider context from the report
“(1) The evidence in this case indicated that prison staff at Winchester Prison are not implementing ACCT plans in accordance with national policy notwithstanding the training they have received and in particular the observations conducted are inadequate. I therefore consider that the process and future training needs to be reviewed ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison Service; that does not assign responsibility.
PFD Monitor interpretation
Failure to train Listeners to pass information about imminent suicide risk to prison staff
Wider context from the report
“(2) The Prison Listener scheme rules as to prisoner confidentiality appeared to be confusing to the listener involved in this case. The HMP Winchester Listener Scheme Protocol dated October 2012 makes no reference to situations where an “at risk” prisoner admits to having made active plans for suicide and threatens to self harm in the future (as in this case). I consider the protocol for Listeners should make it another exception to the principle of confidentiality so that they can pass such information to prison staff and that Listeners should be trained to do so if they have reason to believe there is an imminent risk of suicide even if the prisoner is already subject to an ACCT. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison Service; that does not assign responsibility.
PFD Monitor interpretation
Failure to make Case Notes for all ACCT plans
Wider context from the report
“(3) The case highlighted the limitations of the NOMIS database in relation to recording details of closed ACCT plans meaning that prison staff are frequently unaware of important information about individuals gathered previously. The case showed that despite the national policy requiring Case Notes to be made of all ACCT plans this does not happen for all prisoners so that staff are ignorant even of the fact that there was a previous ACCT in place let alone the reason for it. The ACCT post-closure process should therefore be reviewed. I consider this is particularly relevant where an ACCT is closed and the prisoner is later released and then re-imprisoned or is transferred to a different establishment. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison Service; that does not assign responsibility.
PFD Monitor interpretation
Failure of the Listener Scheme protocol to specify an exception to confidentiality for imminent suicide risk
Wider context from the report
“(2) The Prison Listener scheme rules as to prisoner confidentiality appeared to be confusing to the listener involved in this case. The HMP Winchester Listener Scheme Protocol dated October 2012 makes no reference to situations where an “at risk” prisoner admits to having made active plans for suicide and threatens to self harm in the future (as in this case). I consider the protocol for Listeners should make it another exception to the principle of confidentiality so that they can pass such information to prison staff and that Listeners should be trained to do so if they have reason to believe there is an imminent risk of suicide even if the prisoner is already subject to an ACCT. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison Service; that does not assign responsibility.
PFD Monitor interpretation
Limitations of the NOMIS database in recording details of closed ACCT plans
Wider context from the report
“(3) The case highlighted the limitations of the NOMIS database in relation to recording details of closed ACCT plans meaning that prison staff are frequently unaware of important information about individuals gathered previously. The case showed that despite the national policy requiring Case Notes to be made of all ACCT plans this does not happen for all prisoners so that staff are ignorant even of the fact that there was a previous ACCT in place let alone the reason for it. The ACCT post-closure process should therefore be reviewed. I consider this is particularly relevant where an ACCT is closed and the prisoner is later released and then re-imprisoned or is transferred to a different establishment. ”
Open source report
9 Jan2015
Rutland and North Leicestershire
Concerns raised5
1. Lack of a computer-driven system to flag prescription non-attendance
2. Lack of a specific policy for prisoners requiring 24-hour medical observation where constant medical supervision is unavailable
3. Lack of a computer-driven system to flag lapsed prescriptions
1. Distance and waiting times inhibiting prisoner attendance at the medical centre
2. Failure of welfare checks to ascertain death
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 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 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 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 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 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
12 Mar2014
Teesside
Concerns raised12
1. Absence of arrangements for staff use of CCTV screens
2. Failure to administer prescribed medication
3. Failure by healthcare professionals to attend to system 1 entries
1. Inadequate communication between the Mental Health Team and Healthcare Unit staff about condition and self-harm risk
2. Inadequate observation of patients in the healthcare unit
3. Inadequate communication about required observation between the Mental Health In Reach Team and mental care unit staff
4. Failure to correctly document information provided by mental healthcare nursing staff to Prison Officers
5. Inadequate communication within the Mental Health team about condition and self-harm risk
6. Infrequent observation of CCTV screens
7. Failure by mental health and general nursing staff to take account of system 1 entries
8. Failure to conduct post-closure interviews in accordance with ACCT policy
9. Inadequate quality of CCTV images within the healthcare unit
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Andrew Ronald Hall · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Andrew Ronald Hall, an inmate at HM Holme House Prison, died on 27 March 2009 after causing incised wounds to his neck in a healthcare unit cell. The concerns included inadequate communication and documentation about his mental health and self-harm risk, failures in medication administration and observation, and deficiencies in CCTV quality, monitoring and staff arrangements.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison Service; that does not assign responsibility.
PFD Monitor interpretation
Absence of arrangements for staff use of CCTV screens
Wider context from the report
“11. Arrangements for staff members to use the CCTV screens were absent. (Prison service & Healthcare staff) ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison Service; that does not assign responsibility.
PFD Monitor interpretation
Failure to administer prescribed medication
Wider context from the report
“8. Medication was not administered to the deceased on 23 March 2009 and 24 March 2009 as prescribed. (Medical healthcare staff) ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison Service; that does not assign responsibility.
PFD Monitor interpretation
Failure by healthcare professionals to attend to system 1 entries
Wider context from the report
“5. Insufficient attention was paid by healthcare professionals to the system 1 entries. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison Service; that does not assign responsibility.
PFD Monitor interpretation
Inadequate communication between the Mental Health Team and Healthcare Unit staff about condition and self-harm risk
Wider context from the report
“3. There was inadequate communication between members of the Mental Health Team and the Healthcare Unit staff as to the deceased’s perceived condition and level of risk of self-harm. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison Service; that does not assign responsibility.
PFD Monitor interpretation
Inadequate observation of patients in the healthcare unit
Wider context from the report
“9. The deceased was not adequately observed between 6.30pm and 7.30pm on 27 March 2009. (Healthcare staff/Prison discipline officers) ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison Service; that does not assign responsibility.
PFD Monitor interpretation
Inadequate communication about required observation between the Mental Health In Reach Team and mental care unit staff
Wider context from the report
“4. There was inadequate communication between the Mental Health In Reach Team and the mental care unit staff as to the type and level of observation required when the deceased was re-admitted to the Healthcare Unit on 23 March 2009. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison Service; that does not assign responsibility.
PFD Monitor interpretation
Failure to correctly document information provided by mental healthcare nursing staff to Prison Officers
Wider context from the report
“1. In the assessment of risk and risk management the jury found (inter alia) information provided by mental healthcare nursing staff to Prison Officers was not correctly documented. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison Service; that does not assign responsibility.
PFD Monitor interpretation
Inadequate communication within the Mental Health team about condition and self-harm risk
Wider context from the report
“2. There was inadequate communication between members of the Mental Health team as to the deceased’s condition and the level of risk of self-harm. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison Service; that does not assign responsibility.
PFD Monitor interpretation
Infrequent observation of CCTV screens
Wider context from the report
“12. There was infrequent observation of the CCTV screens on 27 March 2009. (Prison service & Healthcare staff) ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison Service; that does not assign responsibility.
PFD Monitor interpretation
Failure by mental health and general nursing staff to take account of system 1 entries
Wider context from the report
“6. That both mental health staff and general nursing staff inadequately took into account the entry made by ████████ ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison Service; that does not assign responsibility.
PFD Monitor interpretation
Failure to conduct post-closure interviews in accordance with ACCT policy
Wider context from the report
“7. That a post-closure interview in accordance with the (then) ACCT policy should have been conducted. (Prison staff, healthcare staff and Mental Health team) ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison Service; that does not assign responsibility.
PFD Monitor interpretation
Inadequate quality of CCTV images within the healthcare unit
Wider context from the report
“10. The quality of CCTV images within the healthcare unit was inadequate. ( prison service) ”
Open source report
6 Dec2013
County Durham and Darlington
Concerns raised2
1. Delay in summoning an ambulance
2. Failure to ensure that relevant forms are seen during the reception process
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Kirk Duboise · 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

Kirk Duboise arrived at HMP Durham with documents highlighting self-harm risks, but the documents were not seen and an ACCT was not opened. He was found dead in his cell approximately eight hours after arrival; concerns included the failure to identify the relevant forms and a delay in summoning an ambulance.

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 Service; that does not assign responsibility.
PFD Monitor interpretation
Delay in summoning an ambulance
Wider context from the report
“(1) The delay in summoning an ambulance. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison Service; that does not assign responsibility.
PFD Monitor interpretation
Failure to ensure that relevant forms are seen during the reception process
Wider context from the report
“(2) That not all relevant forms were seen by those involved in the reception process one of whose duties at such time was to properly assess the risk of self harm of the new prisoner, particularly a prisoner who had not been in custody before. ”
Open source report
2 Dec2013
Manchester City
Concerns raised5
1. Failure to circulate Risk of Self-Harm / Suicide information promptly to relevant prison functions
2. Lack of a CNOMIS log confirming Senior Wing Officer review of relevant entries after prisoner moves
3. Failure by Healthcare to read and disseminate important Risk of Self-Harm / Suicide documents
1. Failure to ensure that Risk of Self-Harm / Suicide information is read and considered by Senior Wing Officers after prisoner moves
2. Failure to attach existing Risk of Self-Harm / Suicide documents to ACCT documents
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Michael James Meyler · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Michael James Meyler died in hospital on 1 January 2011 after being found hanging by the neck in his prison cell on 28 December 2010 and sustaining a hypoxic brain injury. The principal concerns were that information about his recent self-harm and suicide risk was not adequately circulated, read, or attached to his ACCT plan, limiting the ability of prison staff and healthcare personnel to make informed decisions about his welfare.

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 Service; that does not assign responsibility.
PFD Monitor interpretation
Failure to circulate Risk of Self-Harm / Suicide information promptly to relevant prison functions
Wider context from the report
“1. I am concerned that if a Risk of Self-Harm / Suicide document enters the prison after the prisoner has undergone first Reception Screening, that the information in this document is not adequately circulated to all those who would need to know about it within the prison system. Whilst I am now told that the information is made the subject of an Intelligence or Information Report, which is disseminated (after being “sanitised”) to the Head of Healthcare, the Deputy Head of Healthcare and the Head of Safer Custody, it unclear to me why it is not sent as a priority to Healthcare in the first instance as the information contained within it must be passed on without delay. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison Service; that does not assign responsibility.
PFD Monitor interpretation
Lack of a CNOMIS log confirming Senior Wing Officer review of relevant entries after prisoner moves
Wider context from the report
“4. I am concerned that there is no way of logging that the Senior Wing Officer has read any entries of relevance on CNOMIS when a prisoner moves to their wing, and believe that a method of signing CNOMIS to say that they’ve done so would improve practices within the Prison. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison Service; that does not assign responsibility.
PFD Monitor interpretation
Failure by Healthcare to read and disseminate important Risk of Self-Harm / Suicide documents
Wider context from the report
“5. I am concerned that Healthcare are simply scanning important documents like a Risk of Self-Harm / Suicide document into their system so that they have “a contemporaneous note” rather than actually reading the content. There should be a way of ensuring that these documents are not just scanned to be read in the event that the prisoner has an appointment with someone from Healthcare at a later stage, but that they MUST be read and disseminated in order that they actually make a difference. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison Service; that does not assign responsibility.
PFD Monitor interpretation
Failure to ensure that Risk of Self-Harm / Suicide information is read and considered by Senior Wing Officers after prisoner moves
Wider context from the report
“2. Furthermore, I am concerned that the information in the Risk of Self-Harm / Suicide document is not brought to the attention to the Senior Officers on Wings which the prisoner may move to at a later stage during their incarceration. I believe that a copy of the Risk of Self-Harm / Suicide document is contained in the prisoner’s physical (buff) folder, which goes with them from Wing to Wing, however there needs to be a safeguard to ensure that this information is read and considered at each stage of the prisoner’s term of imprisonment. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Prison Service; that does not assign responsibility.
PFD Monitor interpretation
Failure to attach existing Risk of Self-Harm / Suicide documents to ACCT documents
Wider context from the report
“3. I am concerned that if an ACCT document is opened for any reason that if there should be a Risk of Self-Harm / Suicide document in existence for the prisoner, that it MUST be attached to the ACCT document. In this case the ACCT document was opened principally as an “instrument of support” where it was believed that the prisoner’s primary issues involved contact with his family and his children in particular. It was not known by those who opened the ACCT document and who conducted the various ACCT reviews that he had a history of self-harm which involved both taking an overdose and cutting his wrists on several occasions in the immediate months before he was committed to prison as a consequence of his distress over a long-term relationship breaking down. Furthermore, in the light of the information contained in the Risk of Self-Harm / Suicide document which came to their attention after the death of the deceased, all the Prison Officers involved indicated that they would have referred the deceased on for a Mental Health Inreach Assessment had they known of the details of his previous history. All the Prison Officers concerned felt that they had not been able to make “informed decisions” regarding the welfare of the prisoner concerned as they were not in possession of all the facts at the relevant times. ”
Open source report

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised1

Lack of available mouth protection for resuscitation

Concerns raised1

Failure to design out injury and ligature points from prison cells

Concerns raised1

Lack of effective communication between healthcare personnel at medical emergencies and prison or ambulance control

Concerns raised1

Failure of Approved Premises staff to be familiar with and apply Safe Working Practices Document guidance on resident safety

Concerns raised3

Failure of the prisoner arrival form to sufficiently highlight self-harm and suicide risk to wing staff

Lack of robust management audit of nightly roll checks

Failure of the prisoner arrival form to provide a clear self-harm and suicide risk assessment and response pathway

Concerns raised21

Insufficient availability of safer cells and CCTV-monitored cells

Absence of timely, full and accurate clinical record keeping

Lack of written rationale for self-harm and suicide risk assessments

Inappropriate minimisation of prisoners’ illness or vulnerability during transfer decisions

Inconsistent use of interpretation services during healthcare interviews and ACCT reviews

Overreliance on prisoners’ denials and tick-box recording in suicide and self-harm risk assessment

Inadequate ACCT review during moves from safer cells to ordinary cells

Failure to maintain auditable cross-shift handover of relevant information

Failure to provide coordinated interpreted communication about prisoner transfers

Failure of prison staff to separately record self-harm and suicide risk information

Observation regimes failing to account for predictable observation patterns

Failure to review ACCT risk information and escalate concerns on arrival

Failure to record attendees at healthcare interviews involving prison discipline staff

Failure of staff to understand transfer rationale and destination suitability

Failure to review and record relevant developing medical history before clinical interactions

Failure to ensure prisoners understand transfer reasons and destination regimes

Failure to identify participating healthcare staff and verify completeness of System One records

Failure to undertake holistic and updated self-harm or suicide risk assessment

Failure to hand over relevant ACCT risk information to receiving colleagues

Failure of receiving-wing staff to attend final ACCT case reviews before transfer

Failure to make appropriate documentary records for ACCT transfers

Concerns raised2

Failure to identify increased self-harm risk in prisoners due in Court the following morning

Failure to notify night staff of prisoners due in Court the following morning