Recipient

Lindholme Prison

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First report 8 Jun 2016•Latest report 10 Dec 2019

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
2

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Reports over time

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

  1. South Yorkshire (Eastern)

    AI-generated summary

    Daniel AKAM · Prevention of Future Deaths report

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

    Report summary

    Daniel Akam, a vulnerable prisoner with a history of depression, self-harm, low mood and anxiety, was found unresponsive in his cell with a rope ligature around his neck and was declared deceased. The report identified concerns about an inadequate final ACCT review, missed and inaccurately recorded observations, and inadequate ACCT training for prison officers.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Lindholme Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to accurately record ACCT observations in the ACCT document

    Wider context from the report

    “Failure to carry out ACCT observations recorded in the ACCT log (1) CCTV evidence in the inquest established that 18 observations on Mr Akam were not carried out. (2) The same 18 missed observations were recorded in the ACCT document as having been carried out, when they had not been. (3) Five different prison officers purportedly signed various of these entries. (4) Whilst the above missed observations occurred 24 hours prior to Daniel Akam’s death and were not contributory, the purpose of ACCT observations is to reduce the risk of suicide and self-harm in a vulnerable prisoner. If necessary observations are missed, the risk of suicide and self-harm amongst vulnerable prisoners will likely increase. (5) The fact that the five separate officers did not carry out observations, when they recorded that they did, indicates that the problem is systemic. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Lindholme Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to carry out required ACCT observations for vulnerable prisoners

    Wider context from the report

    “Failure to carry out ACCT observations recorded in the ACCT log (1) CCTV evidence in the inquest established that 18 observations on Mr Akam were not carried out. (2) The same 18 missed observations were recorded in the ACCT document as having been carried out, when they had not been. (3) Five different prison officers purportedly signed various of these entries. (4) Whilst the above missed observations occurred 24 hours prior to Daniel Akam’s death and were not contributory, the purpose of ACCT observations is to reduce the risk of suicide and self-harm in a vulnerable prisoner. If necessary observations are missed, the risk of suicide and self-harm amongst vulnerable prisoners will likely increase. (5) The fact that the five separate officers did not carry out observations, when they recorded that they did, indicates that the problem is systemic. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Lindholme Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Inadequate and insufficiently repeated ACCT training for prison officers

    Wider context from the report

    “ACCT training for prison officers (6) In addition, the evidence revealed that the prison officers did not appear to know what their own obligations and responsibilities were in relation to the ACCT procedure and processes. The general evidential picture was that of inadequate ACCT training for officers, who universally indicated that it would be helpful to have refresher training. (7) Unless adequate and repeated ACCT training is provided for all officers, particularly for those junior and more inexperienced officers, the lives of vulnerable prisoners will not be safeguarded in accordance with the purpose of the ACCT procedure. ”
    Open source report

  2. South Yorkshire (Eastern)

    AI-generated summary

    Anthony Benjamin Patrick Fraser · 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 Benjamin Patrick Fraser had terminal multiple myeloma and died at Doncaster Royal Infirmary on 24 September 2015 after his condition significantly progressed and palliative care was initiated. The report identified the absence of a robust system for conveying summary medical information to receiving A&E departments when inmates are transferred with an acute illness, which could delay diagnosis for other inmates.

    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 Lindholme Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Absence of a robust system for conveying summary medical information to receiving A&E departments during acute illness transfers

    Wider context from the report

    “I heard evidence that the medical records on the electronic Spine One contain a summary overview of a person’s medical status which should be sent to A&E Departments where patients have been referred. This information is readily accessible but in Mr Fraser’s case when he was referred to A&E on 15th August 2015, this information was not conveyed by them to the receiving hospital. I also heard in evidence that there is no system for ensuring that such information is sent and therefore is “hit and miss” as to whether or not it is sent. Whilst I concluded that in Mr Fraser’s case this did not affect the ultimate outcome due to him re-attending four days later and given the very aggressive nature of the cancer from which he was suffering, it is clear that for other inmates with different conditions, failure to provide such information may well delay diagnosis or make it extremely difficult to reach diagnosis. Accordingly consideration needs to be given to implementing a system where such information is conveyed for every such inmate in a timely fashion. Summary of concerns:- 1. Absence of a robust system for conveying summary medical information to receiving A&E departments when inmates are transferred with an acute illness. . ”
    Open source report
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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

0%
0%All other recipients 58%
0%100%

How actions were described at the time

This respondent
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

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