9 Mar 2015 Craig Douglas Bell · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 7 Failure to use CCTV monitoring as an adjunct to ACCT observation procedures View source Failure to share timely information about risk and suicidal or self-harming behaviour between clinical and HMPS staff View source Lack of psychological therapy identification and treatment for prisoners with personality disorders or related traits View source Lack of suitably senior psychiatric clinician attendance at discharge case reviews View source Insufficient availability of safer cells across prison wings for prisoners on ACCT View source Unavailability of cells or facilities fitted with CCTV monitoring View source Lack of graduated risk management planning after transfer to an ordinary wing location View source See 4 more concerns
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No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Craig Douglas Bell · 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 Douglas Bell was found dead in his cell at HMP Manchester on 13 December 2012 after taking his own life by hanging using a self-constructed ligature. He had a history of self-harm and suicidal ideation and was subject to ACCT procedures. The principal concerns included inadequate sharing of risk information, insufficient senior psychiatric involvement in discharge planning, the lack of a graduated risk-management plan, and limited availability of safer or CCTV-monitored cells for prisoners at risk of suicide.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Manchester Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to use CCTV monitoring as an adjunct to ACCT observation procedures
Wider context from the report “6. In 2011 there were a limited number of cells which had been fitted with CCTV monitoring cameras. Very sadly Anthony Raymond Gillard was found dead in such a cell on the 24 December 2011 but that the use of CCTV was not part of his observation regime although he was subject to ACCT procedures . No one looked at or considered the CCTV pictures until after his death but they clearly demonstrated that he had been suffering the effects of over sedation from opiate drugs which no witness had seen or noticed. The use of CCTV monitored cells was discontinued after his death and was not available at the time of Mr Bell’s death . One reason given was that if they were used it required a Prison Officer to be monitoring the CCTV images constantly 24 hours a day. They could , of course , be used as an adjunct or in addition to usual ACCT observation procedures. This would not require constant CCTV monitoring. NOMS have replied to the court’s Regulation 28 PFD report and a copy is attached. I am concerned that if such cells/facilities are not provided and used then there is a risk that prisoners on ACCT’s will continue to be able to kill themselves. The same considerations would apply nationally to the entire HMPS estate. I attach copies of the NOMS response to my Regulation 28 PFD and letter under paragraphs 37/38 of the Chief Coroner’s guidance in relation to Mr Gillard’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 Manchester Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to share timely information about risk and suicidal or self-harming behaviour between clinical and HMPS staff
Wider context from the report “2. I am concerned that the appropriate sharing of information relating to risk and suicidal or self harming behaviour did not take place between the clinical team and HMPS staff . For example, the direct threat of suicide made at the review on the 27 November 2012 was not disclosed to HMPS staff. Appropriate, timely mutual information exchange had not taken place and there is a concern that this may be vital but may be overlooked if steps are not taken to make this a matter of routine. It means that clinical staff have to be able to review the clinical record appropriately and share information with their HMPS 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 Manchester Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of psychological therapy identification and treatment for prisoners with personality disorders or related traits
Wider context from the report “1. The evidence established a significant unmet need for psychological therapies to treat patient prisoner suffering from personality disorders or those suffering from traits of such personality disorders. These prisoners are recognised as being at higher risk of self harm ( which may ultimately result in death ) or suicide. Without NHS Commissioners allocating more resources to identifying and treating such patients there is a concern that further prisoners suffering from these conditions will end up deliberately or accidentally killing themselves.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Manchester Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of suitably senior psychiatric clinician attendance at discharge case reviews
Wider context from the report “3. I am concerned at the lack of attendance of the Consultant Psychiatrist or a suitably qualified and experienced junior colleague at the discharge case review/meeting . In a case of patient still on an ACCT and being discharged to an ordinary wing location without as senior clinician being able to attend and participate in the discharge case review , risk assessment at that stage and risk planning. In this case there was no attendance on the 6 December 2012 and no clinician had seen him since 27 November 2012. This would allow a more sophisticated and timely assessment of risk at that time. Measures to try and reduce or mitigate the risks could then be discussed and put in place in a graduated manner. It is appreciated that such case reviews may have to be rearranged so as to facilitate full attendance. The court has previously identified the concern arising from that fact that no senior clinician took the opportunity at the appropriate time to stand back and take an overall view of the entire circumstances and the risks presented.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Manchester Prison; that does not assign responsibility.
PFD Monitor interpretation Insufficient availability of safer cells across prison wings for prisoners on ACCT
Wider context from the report “5. At the present time the HCC caters for some 22 patient prisoners and has 10 safer cells. I am concerned that the prison has a very limited number of safer cells on a limited number of other wings . At the present time there are no safer cells on all the wings ( invariably single occupancy designed to minimise the risk of using ligatures ). If prisoners are subject to ACCT’s and either transferred from one wing to another or transferred from the HCC to an ordinary wing location ( for what ever reason ) there is no half way house facility providing increased levels of safety . The provision of safer cells has demonstrably reduced the opportunity for fatal self harming in the over whelming majority of cases. Without HMPS investing in the provision of safer cells on every wing or of an increased number of wings there is a concern that prisoners will continue to kill themselves in non safer cells when they are on ACCT’s. The same considerations would apply nationally to the entire HMPS estate.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Manchester Prison; that does not assign responsibility.
PFD Monitor interpretation Unavailability of cells or facilities fitted with CCTV monitoring
Wider context from the report “6. In 2011 there were a limited number of cells which had been fitted with CCTV monitoring cameras. Very sadly Anthony Raymond Gillard was found dead in such a cell on the 24 December 2011 but that the use of CCTV was not part of his observation regime although he was subject to ACCT procedures. No one looked at or considered the CCTV pictures until after his death but they clearly demonstrated that he had been suffering the effects of over sedation from opiate drugs which no witness had seen or noticed. The use of CCTV monitored cells was discontinued after his death and was not available at the time of Mr Bell’s death . One reason given was that if they were used it required a Prison Officer to be monitoring the CCTV images constantly 24 hours a day. They could , of course , be used as an adjunct or in addition to usual ACCT observation procedures. This would not require constant CCTV monitoring. NOMS have replied to the court’s Regulation 28 PFD report and a copy is attached. I am concerned that if such cells/facilities are not provided and used then there is a risk that prisoners on ACCT’s will continue to be able to kill themselves. The same considerations would apply nationally to the entire HMPS estate. I attach copies of the NOMS response to my Regulation 28 PFD and letter under paragraphs 37/38 of the Chief Coroner’s guidance in relation to Mr Gillard’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 Manchester Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of graduated risk management planning after transfer to an ordinary wing location
Wider context from the report “4. I am concerned by the lack of planning or consideration of a graduated risk management plan in such circumstances . This was identified by the clinical reviewer. In other words increased frequency of day time interactions and throughout the whole day and MHIT and Psychiatrist contacts very shortly after the move . In this case the deceased was on the waiting list for a MHIT contact and was due to be seen within 2 weeks by the Psychiatrist.
” Open source report
7 Nov 2014 Colin John Ireland · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 5 Lack of an agreed protocol for seeking approval for emergency release to hospital View source Inadequate training of on-duty Governors in responding to medical emergencies View source Failure of the on-call system to provide reliable telephone access to the responsible approval function View source Failure to prioritise preservation of life over security concerns in emergency medical decisions View source Failure to appropriately act on clinical judgement of a potentially life-threatening condition View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Colin John Ireland · 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
Colin John Ireland, a diabetic prisoner at HMP Wakefield, fell and fractured his left hip during exercise in icy weather on 11 February 2012. After surgery and discharge to the prison healthcare centre, he collapsed and died on 21 February 2012; the inquest recorded pulmonary thromboembolism and deep venous thrombosis. Concerns included delay in transferring him to hospital, difficulties with the high-security prison approval system, and the absence of an agreed protocol and training for Governors responding to medical emergencies.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Manchester Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of an agreed protocol for seeking approval for emergency release to hospital
Wider context from the report “3. That the Governor Grade Officers who gave evidence had differing views as to the action to be taken, in particular in relation to seeking approval from the High Security Prisons Group regarding release to hospital in such circumstances . I consider that there should be an agreed protocol for this and that all on-duty Governors should receive appropriate training regarding responding to medical emergencies of all types to ensure a speedy release to hospital when necessary, obviously without prejudicing appropriate security issues. Although the Duty Governor claimed to acknowledge that preservation of life was paramount, he appeared to be more motivated by Mr Ireland’s notoriety than to the serious issues of his condition which created an unacceptable 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 Manchester Prison; that does not assign responsibility.
PFD Monitor interpretation Inadequate training of on-duty Governors in responding to medical emergencies
Wider context from the report “3. That the Governor Grade Officers who gave evidence had differing views as to the action to be taken , in particular in relation to seeking approval from the High Security Prisons Group regarding release to hospital in such circumstances. I consider that there should be an agreed protocol for this and that all on-duty Governors should receive appropriate training regarding responding to medical emergencies of all types to ensure a speedy release to hospital when necessary, obviously without prejudicing appropriate security issues. Although the Duty Governor claimed to acknowledge that preservation of life was paramount, he appeared to be more motivated by Mr Ireland’s notoriety than to the serious issues of his condition which created an unacceptable 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 Manchester Prison; that does not assign responsibility.
PFD Monitor interpretation Failure of the on-call system to provide reliable telephone access to the responsible approval function
Wider context from the report “2. That the same Governor Grade Officer had difficulty in contacting by telephone the on-call [████████] for the High Security Prison Group to seek permission for Mr Ireland to be sent to hospital. Apparently, [████████] was not responding to her calls . I request that the Director of the High Security Prison Group specifically address this issue in response to this report. Fortunately, the Governor had through his own dealings with [████████] who was then the Director of High Security Prisons, his contact details who was then able to give the relevant permission. I understand that this was an unofficial approach which I do not criticise but would point out that other Duty Governors may not have had access to [████████] number, which would have lengthened the delay . It occurs to me that the on-call system is flawed and should be reviewed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Manchester Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to prioritise preservation of life over security concerns in emergency medical decisions
Wider context from the report “3. That the Governor Grade Officers who gave evidence had differing views as to the action to be taken, in particular in relation to seeking approval from the High Security Prisons Group regarding release to hospital in such circumstances. I consider that there should be an agreed protocol for this and that all on-duty Governors should receive appropriate training regarding responding to medical emergencies of all types to ensure a speedy release to hospital when necessary, obviously without prejudicing appropriate security issues. Although the Duty Governor claimed to acknowledge that preservation of life was paramount, he appeared to be more motivated by Mr Ireland’s notoriety than to the serious issues of his condition which created an unacceptable 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 Manchester Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to appropriately act on clinical judgement of a potentially life-threatening condition
Wider context from the report “1. That a Governor Grade Officer who had sole responsibility for the running of the Prison challenged the clinical judgement and decisions of both an experienced nurse and an on-call GP who believed that Mr Ireland had fractured his hip and that this was a potentially life-threatening condition and that he should be sent to hospital as an emergency .
” Open source report
2 Dec 2013 Michael James Meyler · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 5 Failure to circulate Risk of Self-Harm / Suicide information promptly to relevant prison functions View source Lack of a CNOMIS log confirming Senior Wing Officer review of relevant entries after prisoner moves View source Failure by Healthcare to read and disseminate important Risk of Self-Harm / Suicide documents View source Failure to ensure that Risk of Self-Harm / Suicide information is read and considered by Senior Wing Officers after prisoner moves View source Failure to attach existing Risk of Self-Harm / Suicide documents to ACCT documents View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
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 Manchester Prison; 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 Manchester Prison; 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 Manchester Prison; 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 Manchester Prison; 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 Manchester Prison; 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
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations