Recipient

Leeds Prison

First report 10 Aug 2016•Latest report 9 Sep 2025

Recipient record

Reports, concerns and published responses

Justice · Prison or young offender institution. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 5
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

0%published responses found

0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

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

9 Sep2025
West Yorkshire Eastern
Concerns raised1
1. Lack of effective training and guidance for prison officers managing competing priority tasks
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Brian Burrows (also known as Brian 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

Brian Burrows died on 15 May 2024 after using a ligature while detained at HMP Leeds. He was subject to ACCT monitoring requiring three observations per hour, but was not checked for 53 minutes during a period when the landing was extremely busy and numerous emergency cell bells were activated. The concerns identified were a lack of training and briefing guidance for prison officers on prioritising competing tasks, including emergency cell bells and ACCT 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 Leeds Prison; that does not assign responsibility.
PFD Monitor interpretation
Lack of effective training and guidance for prison officers managing competing priority tasks
Wider context from the report
“(1) The inquest was told that no training is given to prison officers about decision making in dynamic situations where competing priority tasks needs to be completed namely what to do when faced by a number of emergency cell bells and a number of ACCT checks. (2) The inquest was told that briefings delivered by senior staff on the wing do not assist prison officers by providing guidance on how to complete tasks of competing priority. ”
Open source report
23 Jun2021
West Yorkshire Eastern
Concerns raised2
1. Ordinary cells enabling suspension using prison-issued clothing as ligatures
2. Failure to provide cells certified as safer cells in accordance with national standards
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Wayne Boughen · 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

Wayne Boughen was detained at HMP Leeds when he suspended himself from a ligature in his cell on 16 November 2018 and died in hospital the following day. The report raised concerns that HMP Leeds had no certified safer cells meeting national standards, and that he was able to suspend himself using a ligature fashioned from a prison-issued jumper.

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 Leeds Prison; that does not assign responsibility.
PFD Monitor interpretation
Ordinary cells enabling suspension using prison-issued clothing as ligatures
Wider context from the report
“4. In an ordinary cell, Wayne Boughen was able to suspend himself using a ligature fashioned from a prison issue jumper. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Leeds Prison; that does not assign responsibility.
PFD Monitor interpretation
Failure to provide cells certified as safer cells in accordance with national standards
Wider context from the report
“1. At the time of Wayne Boughen’s death, HMP Leeds did not have any cells which were certified safer cells (anti-ligature cells) in accordance with national standards. 2. HMP Leeds still does not have any such certified safer cells. 3. HMP Leeds has a small number of cells which have an increased level of safety as compared with the majority of cells within the prison, but even they do not comply with the certified safer cell standards. ”
Open source report
23 Apr2021
West Yorkshire Eastern
Concerns raised2
1. Failure to communicate the urgent need for ambulance-exit authorisation and have the authorisation prepared
2. Lack of an effective and tested system for admitting emergency ambulance vehicles and facilitating their exit with prisoners
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Guy Clifton Paget · 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

Guy Clifton Paget, a prisoner at HMP Leeds with terminal oesophageal cancer, was found confused in his cell on 16 March 2021 and died at 15:06 that day in an ambulance at the prison gate. The ambulance could not leave because of incorrect paperwork and a malfunctioning vehicle gate. The concerns related to the need for effective, urgent, and tested systems to enable emergency ambulances to enter and leave prisons with prisoners requiring hospital treatment.

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 Leeds Prison; that does not assign responsibility.
PFD Monitor interpretation
Failure to communicate the urgent need for ambulance-exit authorisation and have the authorisation prepared
Wider context from the report
“1. The prison should have effective systems to facilitate the exit of an emergency ambulance from the prison. 2. In this case a decision was made shortly after 13:00 that Mr Paget needed to be taken to hospital. It should have been made clear to the prison managers that the necessary authorisation to exit needed to be prepared as a matter of urgency. At approximately 15:00 hours, however, this was not in place. 3. It is foreseeable that prisons nationally will need to admit paramedics and ambulance vehicles to attend to prisoners at times of emergency – and may then need to leave with the prisoner in the ambulance. An efficient and tested system to manage this process is essential, in order that serving prisoners are provided with an equivalent level of care to that which they could expect in the community. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Leeds Prison; that does not assign responsibility.
PFD Monitor interpretation
Lack of an effective and tested system for admitting emergency ambulance vehicles and facilitating their exit with prisoners
Wider context from the report
“1. The prison should have effective systems to facilitate the exit of an emergency ambulance from the prison. 2. In this case a decision was made shortly after 13:00 that Mr Paget needed to be taken to hospital. It should have been made clear to the prison managers that the necessary authorisation to exit needed to be prepared as a matter of urgency. At approximately 15:00 hours, however, this was not in place. 3. It is foreseeable that prisons nationally will need to admit paramedics and ambulance vehicles to attend to prisoners at times of emergency – and may then need to leave with the prisoner in the ambulance. An efficient and tested system to manage this process is essential, in order that serving prisoners are provided with an equivalent level of care to that which they could expect in the community. ”
Open source report
10 Aug2016
West Yorkshire Eastern
Concerns raised4
1. Unavailability of discharge correspondence to prison healthcare staff
2. Failure to review discharge correspondence by prison healthcare staff
3. Breakdown in communication between hospital and prison at discharge
1. Failure to discontinue prescribed medication when requested by hospital clinicians
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Thomas George Jordan · 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 George Jordan, a remand prisoner at Her Majesty’s Prison, Leeds, became unwell with cardiac symptoms and was admitted to hospital on 6 August 2015. His condition deteriorated, and he died following cardiac arrest at 1955 hours that day; the inquest recorded natural causes. The concerns included continued administration of Digoxin after hospital clinicians requested its discontinuation and a breakdown in communication when he was discharged from hospital, although the report stated there was no evidence that the drug error materially caused or contributed to his death.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Leeds Prison; that does not assign responsibility.
PFD Monitor interpretation
Unavailability of discharge correspondence to prison healthcare staff
Wider context from the report
“(1) Healthcare at the Prison continue to administer the drug Digoxin for several days after the Clinicians at the Hospital had requested that it be discontinued. (2) There had been a breakdown in communication between the Hospital and the Prison when Mr Jordan was discharged. (3) The problem appears to be at the Prison as there was discharge correspondence sent back with him, but this was not immediately available to Healthcare staff and was not reviewed by them. (4) This was an obvious drug error, but there is no evidence to conclude that this has materially caused or contributed to Mr Jordan's death. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Leeds Prison; that does not assign responsibility.
PFD Monitor interpretation
Failure to review discharge correspondence by prison healthcare staff
Wider context from the report
“(1) Healthcare at the Prison continue to administer the drug Digoxin for several days after the Clinicians at the Hospital had requested that it be discontinued. (2) There had been a breakdown in communication between the Hospital and the Prison when Mr Jordan was discharged. (3) The problem appears to be at the Prison as there was discharge correspondence sent back with him, but this was not immediately available to Healthcare staff and was not reviewed by them. (4) This was an obvious drug error, but there is no evidence to conclude that this has materially caused or contributed to Mr Jordan's death. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Leeds Prison; that does not assign responsibility.
PFD Monitor interpretation
Breakdown in communication between hospital and prison at discharge
Wider context from the report
“(1) Healthcare at the Prison continue to administer the drug Digoxin for several days after the Clinicians at the Hospital had requested that it be discontinued. (2) There had been a breakdown in communication between the Hospital and the Prison when Mr Jordan was discharged. (3) The problem appears to be at the Prison as there was discharge correspondence sent back with him, but this was not immediately available to Healthcare staff and was not reviewed by them. (4) This was an obvious drug error, but there is no evidence to conclude that this has materially caused or contributed to Mr Jordan's death. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Leeds Prison; that does not assign responsibility.
PFD Monitor interpretation
Failure to discontinue prescribed medication when requested by hospital clinicians
Wider context from the report
“(1) Healthcare at the Prison continue to administer the drug Digoxin for several days after the Clinicians at the Hospital had requested that it be discontinued. (2) There had been a breakdown in communication between the Hospital and the Prison when Mr Jordan was discharged. (3) The problem appears to be at the Prison as there was discharge correspondence sent back with him, but this was not immediately available to Healthcare staff and was not reviewed by them. (4) This was an obvious drug error, but there is no evidence to conclude that this has materially caused or contributed to Mr Jordan's death. ”
Open source report
10 Aug2016
West Yorkshire Eastern
Concerns raised4
1. Breakdown in hospital-to-prison discharge communication
2. Failure to discontinue medication when directed by hospital clinicians
3. Delayed availability of discharge correspondence to prison healthcare staff
1. Failure by prison healthcare staff to review discharge correspondence
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Thomas George Jordan · 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 George Jordan, a remand prisoner at Her Majesty’s Prison, Leeds, became unwell with cardiac and other medical problems and died in hospital after suffering cardiac arrest on 6 August 2015. Concerns included continued administration of Digoxin after hospital clinicians requested its discontinuation and a breakdown in communication between the hospital and prison, although the report stated there was no evidence that the drug error materially caused or contributed to his death.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Leeds Prison; that does not assign responsibility.
PFD Monitor interpretation
Breakdown in hospital-to-prison discharge communication
Wider context from the report
“(1) Healthcare at the Prison continue to administer the drug Digoxin for several days after the Clinicians at the Hospital had requested that it be discontinued. (2) There had been a breakdown in communication between the Hospital and the Prison when Mr Jordan was discharged. (3) The problem appears to be at the Prison as there was discharge correspondence sent back with him, but this was not immediately available to Healthcare staff and was not reviewed by them. (4) This was an obvious drug error, but there is no evidence to conclude that this has materially caused or contributed to Mr Jordan’s death. (5) I require that the Head of Healthcare at Her Majesty’s Prison liaise with the Medical Director of the Leeds Teaching Hospitals NHS Trust to discuss the feasibility of discharge summaries in respect of Prisons being sent to the Prison’s Healthcare facility electronically to ensure that any directions and advice as to future care are received promptly and can take immediate effect. (6) Should there be issues of patient confidentiality, this can be addressed by the Prison having a secure email facility dedicated for this purpose. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Leeds Prison; that does not assign responsibility.
PFD Monitor interpretation
Failure to discontinue medication when directed by hospital clinicians
Wider context from the report
“(1) Healthcare at the Prison continue to administer the drug Digoxin for several days after the Clinicians at the Hospital had requested that it be discontinued. (2) There had been a breakdown in communication between the Hospital and the Prison when Mr Jordan was discharged. (3) The problem appears to be at the Prison as there was discharge correspondence sent back with him, but this was not immediately available to Healthcare staff and was not reviewed by them. (4) This was an obvious drug error, but there is no evidence to conclude that this has materially caused or contributed to Mr Jordan’s death. (5) I require that the Head of Healthcare at Her Majesty’s Prison liaise with the Medical Director of the Leeds Teaching Hospitals NHS Trust to discuss the feasibility of discharge summaries in respect of Prisons being sent to the Prison’s Healthcare facility electronically to ensure that any directions and advice as to future care are received promptly and can take immediate effect. (6) Should there be issues of patient confidentiality, this can be addressed by the Prison having a secure email facility dedicated for this purpose. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Leeds Prison; that does not assign responsibility.
PFD Monitor interpretation
Delayed availability of discharge correspondence to prison healthcare staff
Wider context from the report
“(1) Healthcare at the Prison continue to administer the drug Digoxin for several days after the Clinicians at the Hospital had requested that it be discontinued. (2) There had been a breakdown in communication between the Hospital and the Prison when Mr Jordan was discharged. (3) The problem appears to be at the Prison as there was discharge correspondence sent back with him, but this was not immediately available to Healthcare staff and was not reviewed by them. (4) This was an obvious drug error, but there is no evidence to conclude that this has materially caused or contributed to Mr Jordan’s death. (5) I require that the Head of Healthcare at Her Majesty’s Prison liaise with the Medical Director of the Leeds Teaching Hospitals NHS Trust to discuss the feasibility of discharge summaries in respect of Prisons being sent to the Prison’s Healthcare facility electronically to ensure that any directions and advice as to future care are received promptly and can take immediate effect. (6) Should there be issues of patient confidentiality, this can be addressed by the Prison having a secure email facility dedicated for this purpose. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Leeds Prison; that does not assign responsibility.
PFD Monitor interpretation
Failure by prison healthcare staff to review discharge correspondence
Wider context from the report
“(1) Healthcare at the Prison continue to administer the drug Digoxin for several days after the Clinicians at the Hospital had requested that it be discontinued. (2) There had been a breakdown in communication between the Hospital and the Prison when Mr Jordan was discharged. (3) The problem appears to be at the Prison as there was discharge correspondence sent back with him, but this was not immediately available to Healthcare staff and was not reviewed by them. (4) This was an obvious drug error, but there is no evidence to conclude that this has materially caused or contributed to Mr Jordan’s death. (5) I require that the Head of Healthcare at Her Majesty’s Prison liaise with the Medical Director of the Leeds Teaching Hospitals NHS Trust to discuss the feasibility of discharge summaries in respect of Prisons being sent to the Prison’s Healthcare facility electronically to ensure that any directions and advice as to future care are received promptly and can take immediate effect. (6) Should there be issues of patient confidentiality, this can be addressed by the Prison having a secure email facility dedicated for this purpose. ”
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 effective training and guidance for prison officers managing competing priority tasks

Concerns raised2

Ordinary cells enabling suspension using prison-issued clothing as ligatures

Failure to provide cells certified as safer cells in accordance with national standards

Concerns raised2

Failure to communicate the urgent need for ambulance-exit authorisation and have the authorisation prepared

Lack of an effective and tested system for admitting emergency ambulance vehicles and facilitating their exit with prisoners

Concerns raised4

Unavailability of discharge correspondence to prison healthcare staff

Failure to review discharge correspondence by prison healthcare staff

Breakdown in communication between hospital and prison at discharge

Failure to discontinue prescribed medication when requested by hospital clinicians

Concerns raised4

Breakdown in hospital-to-prison discharge communication

Failure to discontinue medication when directed by hospital clinicians

Delayed availability of discharge correspondence to prison healthcare staff

Failure by prison healthcare staff to review discharge correspondence