15 Jun 2026 Mr Arron Hamer · Prevention of Future Deaths report Manchester North
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Concerns raised 1 Lack of refresher training in basic life support for prison officers View source
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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
Mr Arron Hamer · 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
Mr Arron Hamer, who had been in custody since 2009 and was held at HMP Buckley Hall, was found hanging in his cell on 18 June 2026. The principal concern was that prison officers did not cut the ligature or commence CPR for nearly three minutes, and that most prison officers do not receive mandatory refresher training in basic life support after their initial training.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Lack of refresher training in basic life support for prison officers
Wider context from the report “(1) The Court heard there is no mandatory refresher training on basic life support for prison officers after they have conducted their initial prison officer training .
If they do the first aid at work course this has to be refreshed every three years but only certain officers do this . For the majority they do not have refresher training .
” Open source report
21 May 2026 George Edward James Haldenby · Prevention of Future Deaths report Dorset
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Concerns raised 4 Delays in processing hospital-issued FP10 prescriptions in prisons without 24-hour healthcare provision View source Incomplete availability of critical medications held in prison View source Lack of local policy or process for managing out-of-hours FP10 prescriptions View source Lack of mandatory refresher training in first aid and CPR for prison staff View source See 1 more concern
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George Edward James Haldenby · 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
George Edward James Haldenby was a serving prisoner with severe heart failure who collapsed at HMP The Verne on 29 January 2022 and died that day at Dorset County Hospital. The report identifies delays in receiving an increased dose of Furosemide, and a delay in recognising the collapse and starting CPR, as substantive concerns. It also raises concerns about the absence of regular refresher training in first aid and CPR and the lack of a clear process for handling hospital prescriptions issued outside prison healthcare hours.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Delays in processing hospital-issued FP10 prescriptions in prisons without 24-hour healthcare provision
Wider context from the report “In prisons without 24 hour healthcare provision, if a prisoner receives treatment at a hospital and is issued with a medication prescription on a FP10 form, this cannot be processed at the prison in the absence of a doctor or prescribing nurse , and pharmacies in hospitals are not always open 24 hours a day for it to be dispensed as TTO medication. This means there will be a delay in prisoners receiving necessary and lifesaving medication over a weekend or bank holiday period until staff are in the prison who can action the prescription.
” 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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Incomplete availability of critical medications held in prison
Wider context from the report “Whilst at HMP The Verne there is now a duty Doctor who can be called upon out of hours to progress such prescriptions, there is a lack of local policy or process to ensure the prison and healthcare staff have an understanding of how to deal with the situation should a FP10 be issued outside of hours when a prescribing health professional is not available in the prison to ensure a prisoner receives necessary medications without delay. Although critical medications are held at the prison in a locked cabinet, not all medication are included and Furosemide, which was critical in George’s care, is one of those that is not held by the prison as a critical medicine .
” 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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Lack of local policy or process for managing out-of-hours FP10 prescriptions
Wider context from the report “Whilst at HMP The Verne there is now a duty Doctor who can be called upon out of hours to progress such prescriptions, there is a lack of local policy or process to ensure the prison and healthcare staff have an understanding of how to deal with the situation should a FP10 be issued outside of hours when a prescribing health professional is not available in the prison to ensure a prisoner receives necessary medications without delay. Although critical medications are held at the prison in a locked cabinet, not all medication are included and Furosemide, which was critical in George’s care, is one of those that is not held by the prison as a critical medicine.
” 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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Lack of mandatory refresher training in first aid and CPR for prison staff
Wider context from the report “After prison officers and prison staff carry out their induction training which covers basic first aid training including the delivery of cardio pulmonary resuscitation (CPR), there is no further mandatory refresher training on first aid or CPR . During the evidence, a Custodial Manager at HMP the Verne stated that the last time he had first aid or CPR training was in 1991, 35 years ago, when he started as a prison officer. Whilst there is a requirement to have a duty first aider on site 24 hours a day, without all staff being suitably and regularly trained in signs of collapse and administering CPR , there could be a delay in delivering effective CPR as it may take time for the duty first aider to get to the prisoner, and a future death could occur.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Undertake a comprehensive Training Needs Analysis to inform a structured First Aid training plan at HMP The Verne.
Verbatim wording from the response “HMP The Verne is undertaking a comprehensive Training Needs Analysis to inform the development of a structured First Aid training plan. From July 2026, the prison intends to deliver monthly three-day First Aid at Work training programmes. These sessions will be jointly led by the Head of Business Assurance and supported by the Health and Safety Manager. The programme is designed to increase the number of staff trained to a recognised First Aid at Work standard and strengthen the prison’s emergency response capability. Increasing the number of staff trained in First Aid at Work will enable the implementation of a 24-hour, seven-day nominated staff rota, to ensure a coordinated and timely response to emergencies. The initial rollout of training will prioritise key staff groups, including Custodial Managers, Supervising Officers, Care and Separation Unit staff, and Induction Wing staff.” Source location 2026-0312 - Response from HM Prison and Probation Service
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue collaborative work between prison and healthcare managers to establish local out-of-hours medication processes with defined escalation routes, roles and accountability.
Verbatim wording from the response “Further collaborative work is being undertaken between prison and healthcare managers to establish a clear and robust local process incorporating defined escalation routes, roles and accountability measures. This will ensure that staff have the necessary clarity and confidence to respond appropriately when out-of-hours medication issues arise, supporting timely access to essential treatment and continuity of care.” Source location 2026-0312 - Response from HM Prison and Probation Service
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide ongoing refresher first-aid resources and learning materials, including bespoke first-on-scene emergency-response videos for prison and frontline staff.
Verbatim wording from the response “You will be aware that all new prison officers receive mandatory Emergency First Aid and CPR training as part of their foundation programme. This training remains valid for three years and is subject to requalification. In addition, the HMPPS First Aid Policy Framework (re-issued in August 2023) requires Governors to maintain sufficient first aid provision based on a local First Aid Needs Assessment. To support staff capability, HMPPS provides ongoing refresher resources and learning materials to maintain and enhance first aid knowledge and skills. For example, HMPPS has worked with St John Ambulance to develop bespoke “first-on-scene” video resources for prison officers and frontline staff, offering practical guidance on responding to a range of emergency situations prior to the arrival of healthcare professionals.” Source location 2026-0312 - Response from HM Prison and Probation Service
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver monthly three-day First Aid at Work programmes from July 2026, supported by a forward-planned schedule of initial and refresher training.
Verbatim wording from the response “HMP The Verne is undertaking a comprehensive Training Needs Analysis to inform the development of a structured First Aid training plan. From July 2026, the prison intends to deliver monthly three-day First Aid at Work training programmes. These sessions will be jointly led by the Head of Business Assurance and supported by the Health and Safety Manager. The programme is designed to increase the number of staff trained to a recognised First Aid at Work standard and strengthen the prison’s emergency response capability. Increasing the number of staff trained in First Aid at Work will enable the implementation of a 24-hour, seven-day nominated staff rota, to ensure a coordinated and timely response to emergencies. The initial rollout of training will prioritise key staff groups, including Custodial Managers, Supervising Officers, Care and Separation Unit staff, and Induction Wing staff.” Source location 2026-0312 - Response from HM Prison and Probation Service
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsibility for the out-of-hours medication process has been referred to Oxleas NHS Foundation Trust for consideration and response.
Verbatim wording from the response “Although your concerns about the lack of policy/process for healthcare staff around accessing out of hours or hospital prescribed medication has been referred to Oxleas NHS Foundation Trust for their separate consideration and response, HMPPS has also considered whether there is any supportive action that it can take. Oxleas NHS Foundation Trust has confirmed that a formal process and guidance for healthcare teams regarding the management of medicines outside normal operating hours was implemented in September 2024. This is supported by a Standard Operating Procedure, which provides clear direction on the sourcing and provision of prescribed medication during evenings, weekends, and bank holidays.” Source location 2026-0312 - Response from HM Prison and Probation Service
Open published response
7 May 2026 Alan Joseph Whelan · Prevention of Future Deaths report West Yorkshire Eastern
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Concerns raised 1 Failure to provide a mental health assessment within 24 hours of transfer to the Segregation Unit for prisoners on an open ACCT document View source
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AI-generated summary
Alan Joseph Whelan · 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
Alan Whelan, a serving prisoner at HMP Leeds, was moved to the Segregation Unit after starting a fire in his cell while on an open ACCT document. A required mental health assessment was not carried out within 24 hours, and he was later found hanging in his cell and died in hospital on 30 December 2024. Concerns included non-compliance with the mandatory assessment requirement and failures relating to the frequency of ACCT observations.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to provide a mental health assessment within 24 hours of transfer to the Segregation Unit for prisoners on an open ACCT document
Wider context from the report “A mandatory requirement that a prisoner on an open ACCT document should have a mental health assessment within 24 hours of being transferred to the Segregation Unit was not complied with. Alan took steps that caused his death after that 24-hour window had closed. There was scant acknowledgement of this breach of a standing instruction from the witnesses who gave evidence to the inquest. The possibility that not carrying out such an assessment made no difference to the outcome is obvious. But that possibility neither explains nor excuses the failure to comply with the instruction , especially where it is unclear whether that failure was inadvertent or deliberate, and if deliberate, with what justification.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with HMPPS nationally and locally to establish communications identifying ACCT patients moved to segregation.
Verbatim wording from the response “In addition, PPG will be working with HMPPS both at site level and nationally to ensure effective communications are in place between the two organisations to make sure patients who are on ACCTs and then moved to segregation are identified,” Source location Response from Practice Plus Group
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Obtain site-level confirmation that the communication was actioned and monitor compliance regionally through the mental health steering group.
Verbatim wording from the response “Further, PPG has a mental health steering group, which meets quarterly, and is attended by all regional mental health leads, the National Mental Health & Psychosocial Lead, the Lead Psychiatrist and the Lead Psychologist. On the agenda at the next meeting, due to take place in July 2026, is obtaining confirmation that the aforementioned communication has been actioned at site levels and confirmation that compliance is being monitored at a regional level.” Source location Response from Practice Plus Group
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise the national mental health policy to require 24-hour mental health assessments for relevant ACCT prisoners placed in segregation.
Verbatim wording from the response “PPG acknowledge that its policies do not contain an explicit requirement that matches PSO1700, i.e. that:” Source location Response from Practice Plus Group
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Communicate the PSO1700 assessment requirement to regional managers and mental health leads, requesting consistent implementation across services.
Verbatim wording from the response “In the meantime, communication has been sent to PPG’s HIJ regional managers and regional mental health leads highlighting the requirement within PSO1700 and requesting that this is consistently implemented across all of our services. The role of PPG’s regional managers and regional mental health leads is to implement, communicate and embed processes and ensure compliance with the same.” Source location Response from Practice Plus Group
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the Take ACCTion audit to check compliance with PSO1700 and whether required mental health assessments occurred.
Verbatim wording from the response “PPG already has a process in place, within its audit schedule, to audit ACCTs, which is called Take ACCTion. It is intended that the Take ACCTion audit will be updated to include whether there has been compliance with PSO1700, to check if a mental health assessment” Source location Response from Practice Plus Group
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The PS1700 requirement is an HMPPS policy outside PPG’s control, so PPG limits its response to healthcare matters.
Verbatim wording from the response “Practice Plus Group (“PPG”) would like to clarify that the document PS1700, referred to in the Regulation 28 report dated 7 May 2026, is a HMPPS policy and is not under the control of PPG.” Source location Response from Practice Plus Group
Open published response
8 Apr 2026 Jonathan Mark Thornton · Prevention of Future Deaths report Nottinghamshire
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Concerns raised 6 Unavailability of NOMIS/DPS alerts to Healthcare Staff View source Lack of a formal mechanism for sharing prisoners’ mental health risks and triggers with operational prison staff View source Failure to equip operational prison staff to identify and report behavioural deterioration View source Failure to communicate monitoring plans to the healthcare team View source Insufficiently detailed and visible NOMIS/DPS risk-alert categorisation for operational prison staff View source Lack of formal information sharing and reliable handover between the CFT and Prison Healthcare View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Jonathan Mark Thornton · 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
Jonathan Mark Thornton died at Queens Medical Centre in Nottingham on 12 July 2024 after sustaining a severe head injury in an attack by a fellow inmate at HMP Nottingham on 28 June 2024. The report raises concerns about inadequate information sharing between community forensic, prison healthcare and operational prison staff, and about the categorisation and visibility of risk alerts on NOMIS/DPS, creating a risk of future deaths.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Unavailability of NOMIS/DPS alerts to Healthcare Staff
Wider context from the report “3. Categorisation and visibility of alerts on NOMIS/DPS
I heard that NOMIS/DPS has preset categorisation of alerts. The categories are limited and broad. This means that ‘violent’ prisoners – regardless of the particulars of that violence – will all be categorised together. This case illustrated quite clearly that there are certain categories of offender who require better particularisation of their risk. In this case, that was those prisoners with a history of assaulting fellow inmates. I was told that unless a prisoner has assaulted a cellmate, which would be subject to its own assessment, the operational prison staff would not necessarily know whether their violent behaviour was aimed at prison officers, other prisoners or simply a genera violent behaviour linked to their offending. Clearly, each of these categories gives rise to a particular risk within a prison setting. I am concerned that if more detailed categorisation and/or information is not provided to the operational prison staff within NOMIS/DPS alerts, with clear visibility, this gives rise to a risk of future death. I understand that this is controlled nationally.
Moreover, I understand that the Healthcare Staff are unable to view NOMIS/DPS alerts . This gives rise to the same risk .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Lack of a formal mechanism for sharing prisoners’ mental health risks and triggers with operational prison staff
Wider context from the report “2. Information sharing between Prison Healthcare and Operational Prison Staff.
This case illustrated a lack of communication and information sharing between Prison Healthcare and the Operational Prison Staff which was concerning to me. I heard evidence that Prison Healthcare had in place a quasi ‘watch and wait’ plan for monitoring a potentially high-risk inmate. Not only was this plan not communicated to all of the healthcare team, but it relied upon reporting of deterioration in behaviours from operational prison staff who were completely unaware that (i) they were being tasked with this role; and (ii) what to look for. Furthermore, the operational prison staff told me that having a broad understanding (within the confines of confidentiality) of a prisoner’s mental health risks and triggers would improve the safety and security of the prison for the officers and prisoners . It would enable them to properly assess and manage risk, but that there was no effective mechanism in place by which to achieve this . I am concerned that the lack of formal information sharing between the two departments gives rise to a risk of future 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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to equip operational prison staff to identify and report behavioural deterioration
Wider context from the report “2. Information sharing between Prison Healthcare and Operational Prison Staff.
This case illustrated a lack of communication and information sharing between Prison Healthcare and the Operational Prison Staff which was concerning to me. I heard evidence that Prison Healthcare had in place a quasi ‘watch and wait’ plan for monitoring a potentially high-risk inmate. Not only was this plan not communicated to all of the healthcare team, but it relied upon reporting of deterioration in behaviours from operational prison staff who were completely unaware that (i) they were being tasked with this role; and (ii) what to look for . Furthermore, the operational prison staff told me that having a broad understanding (within the confines of confidentiality) of a prisoner’s mental health risks and triggers would improve the safety and security of the prison for the officers and prisoners. It would enable them to properly assess and manage risk, but that there was no effective mechanism in place by which to achieve this. I am concerned that the lack of formal information sharing between the two departments gives rise to a risk of future 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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate monitoring plans to the healthcare team
Wider context from the report “2. Information sharing between Prison Healthcare and Operational Prison Staff.
This case illustrated a lack of communication and information sharing between Prison Healthcare and the Operational Prison Staff which was concerning to me. I heard evidence that Prison Healthcare had in place a quasi ‘watch and wait’ plan for monitoring a potentially high-risk inmate. Not only was this plan not communicated to all of the healthcare team , but it relied upon reporting of deterioration in behaviours from operational prison staff who were completely unaware that (i) they were being tasked with this role; and (ii) what to look for. Furthermore, the operational prison staff told me that having a broad understanding (within the confines of confidentiality) of a prisoner’s mental health risks and triggers would improve the safety and security of the prison for the officers and prisoners. It would enable them to properly assess and manage risk, but that there was no effective mechanism in place by which to achieve this. I am concerned that the lack of formal information sharing between the two departments gives rise to a risk of future 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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Insufficiently detailed and visible NOMIS/DPS risk-alert categorisation for operational prison staff
Wider context from the report “3. Categorisation and visibility of alerts on NOMIS/DPS
I heard that NOMIS/DPS has preset categorisation of alerts. The categories are limited and broad . This means that ‘violent’ prisoners – regardless of the particulars of that violence – will all be categorised together. This case illustrated quite clearly that there are certain categories of offender who require better particularisation of their risk. In this case, that was those prisoners with a history of assaulting fellow inmates. I was told that unless a prisoner has assaulted a cellmate, which would be subject to its own assessment, the operational prison staff would not necessarily know whether their violent behaviour was aimed at prison officers, other prisoners or simply a genera violent behaviour linked to their offending. Clearly, each of these categories gives rise to a particular risk within a prison setting. I am concerned that if more detailed categorisation and/or information is not provided to the operational prison staff within NOMIS/DPS alerts, with clear visibility , this gives rise to a risk of future death. I understand that this is controlled nationally.
Moreover, I understand that the Healthcare Staff are unable to view NOMIS/DPS alerts. This gives rise to the same risk.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Lack of formal information sharing and reliable handover between the CFT and Prison Healthcare
Wider context from the report “1. Information sharing between the CFT and Prison Healthcare.
During the course of the inquest, I heard that there had been various barriers to information sharing between the community forensic team and prison healthcare. There was no formal system in place for the handover of information between these teams at the time of Jonathan’s death or at the conclusion of the inquest. Prison Healthcare staff were often unavailable or uncontactable for handover meetings . The handover of information between CFT and Prison Healthcare is vital for the risk assessment and management of prisoners who are known to the CFT (often some of the most complex and high-risk prisoners). I am concerned that the lack of formal information sharing between the two departments gives rise to a risk of future death.
” Open source report
24 Mar 2026 Thomas Daniel RUGGIERO · Prevention of Future Deaths report Kent and Medway
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Concerns raised 2 Insufficient and unclear communication between prison staff View source Insufficient numbers of experienced prison officers across the prison estate View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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Thomas Daniel RUGGIERO · 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 Daniel Ruggiero, a 39-year-old man serving a prison sentence at HMP Swaleside, was found unresponsive in his cell on 16 November 2024 after ligaturing himself and died later that day. The report raised concerns about insufficient communication between prison staff and the wider prison estate’s high levels of inexperienced officers, linked to recruitment and retention issues.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Insufficient and unclear communication between prison staff
Wider context from the report “(1) The evidence was that in November 2024, up to (and possibly more than) 90% of prison officers at HMP Swaleside were new and still in their probationary period. I was told in evidence by a Supervising Officer (SO) that on 16 November 2024, he 'possibly did not have the right mix of staff in terms of skills and experience to keep the wing safe'.
In this inquest, the jury found that, "the communication between prison staff was insufficient and lacked clarity ".
I was told that the level of officers still in their probationary period has now reduced. I was also made aware of the 'Urgent Notification' (UN) from HM Chief Inspector of Prisons in relation to HMP Swaleside (December 2025), which included in the rationale, "Staff, many of whom lacked experience, were not confident in challenging poor behaviour and there was a lack of order and control." This suggests to me that the issue is ongoing.
When exploring the evidence further, I was told that issues relating to the recruitment and retention of prison officers were significant and that this is not something that it is confined only to HMP Swaleside. There was evidence that this is a much wider issue.
Without sufficient numbers of experienced prison officers across the prison estate, the staffing issues seen in this particular inquest are likely not isolated. I highlight to you my concern that high levels of inexperienced staff will undoubtedly contribute to future deaths of those in custody.
” 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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Insufficient numbers of experienced prison officers across the prison estate
Wider context from the report “(1) The evidence was that in November 2024, up to (and possibly more than) 90% of prison officers at HMP Swaleside were new and still in their probationary period . I was told in evidence by a Supervising Officer (SO) that on 16 November 2024, he 'possibly did not have the right mix of staff in terms of skills and experience to keep the wing safe '.
In this inquest, the jury found that, "the communication between prison staff was insufficient and lacked clarity".
I was told that the level of officers still in their probationary period has now reduced. I was also made aware of the 'Urgent Notification' (UN) from HM Chief Inspector of Prisons in relation to HMP Swaleside (December 2025), which included in the rationale, "Staff, many of whom lacked experience, were not confident in challenging poor behaviour and there was a lack of order and control. " This suggests to me that the issue is ongoing.
When exploring the evidence further, I was told that issues relating to the recruitment and retention of prison officers were significant and that this is not something that it is confined only to HMP Swaleside . There was evidence that this is a much wider issue.
Without sufficient numbers of experienced prison officers across the prison estate , the staffing issues seen in this particular inquest are likely not isolated. I highlight to you my concern that high levels of inexperienced staff will undoubtedly contribute to future deaths of those in custody.
” Open source report
24 Mar 2026 Ronald William MEIKLE · Prevention of Future Deaths report Milton Keynes
View report summary
Concerns raised 16 Weak supervision and staff-prisoner engagement View source Failure to maintain a clear and current drug under the influence policy View source Delays or insufficiency in psychiatric assessment and proactive mental health review View source Failure to recognise suspected synthetic cannabinoid intoxication promptly during collapse response View source Insufficient staffing capacity View source Restricted prison regimes View source Insufficiently robust identification and management of prisoners remaining behind their door because of vulnerability View source Inadequate welfare observations View source Inconsistent identification, assessment, monitoring and response to prisoners under the influence of illicit substances View source Failure to escalate prisoners with cumulative vulnerability indicators into safer custody procedures View source Availability of illicit substances in custody View source Failure to reliably consolidate and share relevant prisoner risk information View source Failure to maintain unobstructed observation panels for effective visual welfare checks View source Delays in supplying material information relevant to death investigations and future-death prevention View source Failure to implement sufficient and sustained remedial action on identified prison safety concerns View source Failure to recognise IPP status as a material vulnerability requiring structured support and review View source See 13 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Ronald William MEIKLE · 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
Ronald William Meikle was found unresponsive in his single-occupancy cell at HMP Woodhill on 30 April 2024 and was pronounced dead at 09:43. The report identified concerns about illicit substances, inconsistent responses to suspected intoxication, fragmented information-sharing, inadequate welfare observations, management of self-isolation and vulnerability, absence of ACCT proceedings, mental-health input, emergency response, staffing, and recurring systemic problems at the prison.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Weak supervision and staff-prisoner engagement
Wider context from the report “Concern 10: Staffing, supervision and regime limitations
The evidence before the court, including wider inspection material, raised concern that staffing pressures, weak supervision, poor staff-prisoner engagement , restricted regimes, and inadequate welfare observations may materially increase the risk of undetected drug use, delayed discovery of collapsed prisoners and failure to identify vulnerable men in need of intervention.
” 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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain a clear and current drug under the influence policy
Wider context from the report “Concern 2: Failure consistently to identify, record and respond to prisoners under the influence
The evidence showed concerns about the consistency with which prisoners suspected or found to be under the influence of illicit substances were identified, clinically assessed, monitored, referred to substance misuse services, and managed under prison and healthcare processes. There was evidence that episodes of apparent intoxication were not always met with a consistent healthcare response or documented follow-up. The head of service had an understanding of the drug under the influence policy that was starkly different to the written document . There had been multiple updates of the drug policy which were difficult to identify as to when the policy was updated / revised . I am concerned that prisoners at acute risk of overdose or deterioration may therefore not receive timely intervention.
” 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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Delays or insufficiency in psychiatric assessment and proactive mental health review
Wider context from the report “Concern 8: Delay or insufficiency in mental health and psychiatric input
The evidence raised concern that prisoners with known vulnerabilities, substance misuse history and symptoms of deteriorating mental health may not always receive timely psychiatric assessment or sufficiently proactive mental health review . Delays in specialist assessment can increase the risk of unmanaged distress, relapse to substance use and 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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise suspected synthetic cannabinoid intoxication promptly during collapse response
Wider context from the report “Concern 9: Emergency response to suspected synthetic cannabinoid collapse
The evidence raised concern about whether staff responding to collapse were adequately trained and equipped to consider synthetic cannabinoid intoxication promptly as a possible cause . Synthetic cannabinoid use can cause rapid deterioration and death. If staff do not recognise that possibility, there is a risk of delay in appropriate emergency action, clinical escalation and treatment .
” 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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Insufficient staffing capacity
Wider context from the report “Concern 10: Staffing, supervision and regime limitations
The evidence before the court, including wider inspection material, raised concern that staffing pressures , weak supervision, poor staff-prisoner engagement, restricted regimes, and inadequate welfare observations may materially increase the risk of undetected drug use, delayed discovery of collapsed prisoners and failure to identify vulnerable men in need of intervention.
” 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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Restricted prison regimes
Wider context from the report “Concern 10: Staffing, supervision and regime limitations
The evidence before the court, including wider inspection material, raised concern that staffing pressures, weak supervision, poor staff-prisoner engagement, restricted regimes , and inadequate welfare observations may materially increase the risk of undetected drug use, delayed discovery of collapsed prisoners and failure to identify vulnerable men in need of intervention.
” 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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Insufficiently robust identification and management of prisoners remaining behind their door because of vulnerability
Wider context from the report “Concern 5: Management of self-isolation, debt, fear and vulnerability
The evidence suggested that Mr Meikle had vulnerabilities connected to self-isolation, debt, fear of other prisoners, possible coercion or bullying, mental ill-health, and substance misuse. I am concerned that the systems for identifying and managing prisoners who remain behind their door because of debt, fear, vulnerability or drug-related pressures were not sufficiently robust, coordinated or 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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Inadequate welfare observations
Wider context from the report “Concern 10: Staffing, supervision and regime limitations
The evidence before the court, including wider inspection material, raised concern that staffing pressures, weak supervision, poor staff-prisoner engagement, restricted regimes, and inadequate welfare observations may materially increase the risk of undetected drug use, delayed discovery of collapsed prisoners and failure to identify vulnerable men in need of intervention.
” 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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Inconsistent identification, assessment, monitoring and response to prisoners under the influence of illicit substances
Wider context from the report “Concern 2: Failure consistently to identify, record and respond to prisoners under the influence
The evidence showed concerns about the consistency with which prisoners suspected or found to be under the influence of illicit substances were identified, clinically assessed, monitored, referred to substance misuse services, and managed under prison and healthcare processes . There was evidence that episodes of apparent intoxication were not always met with a consistent healthcare response or documented follow-up . The head of service had an understanding of the drug under the influence policy that was starkly different to the written document. There had been multiple updates of the drug policy which were difficult to identify as to when the policy was updated / revised. I am concerned that prisoners at acute risk of overdose or deterioration may therefore not receive timely intervention.
” 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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate prisoners with cumulative vulnerability indicators into safer custody procedures
Wider context from the report “Concern 6: Absence of ACCT despite identifiable indicators of vulnerability
The concern is not that ACCT documentation disclosed a missed risk factor, but that the available materials show Mr Meikle was not subject to ACCT proceedings, despite evidence shortly before death of self-isolation, debt-related vulnerability, known substance misuse and reduced engagement. This occurred in an establishment where HM Inspectorate of Prisons had already identified weaknesses in ACCT management and welfare checking during an unannounced inspection in 2023 and had issued an Urgent Notification which included reference to "frailties in ACCT case management". I later became aware of a second Urgent Notification issued in March 2026, shortly after completion of Mr Meikle's inquest that once again identified "frailties in ACCT case management". I am concerned that prisoners presenting with cumulative indicators of vulnerability may not be escalated into safer custody procedures when required , thereby increasing the risk that deteriorating welfare is not recognised or managed.
” 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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Availability of illicit substances in custody
Wider context from the report “Concern 1: Availability of illicit substances in custody
The evidence indicated that illicit drugs ████████ were readily available within HMP Woodhill . Material before the court showed this was not an isolated issue but part of a wider and continuing prison safety problem at HMP Woodhill and likely other prisons . The availability of synthetic cannabinoids in custody creates a foreseeable risk of sudden collapse, respiratory compromise, cardiac arrest, psychosis, violence, self-harm and 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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to reliably consolidate and share relevant prisoner risk information
Wider context from the report “Concern 3: Fragmented information-sharing and record keeping
The evidence demonstrated that relevant risk information was spread across multiple recording systems and was not always shared effectively between operational staff and clinical teams . This included information relevant to substance misuse, mental health, debt, bullying or coercion, self-isolation, intelligence about threats, recent presentation under the influence. Where critical safety information is held in separate systems and not reliably brought together , there is a foreseeable risk that warning signs will be missed and protective action delayed with obvious risk of harm or 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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain unobstructed observation panels for effective visual welfare checks
Wider context from the report “Concern 4: Blocked observation panels and inadequate visual welfare checks
The evidence raised serious concern that blocked observation panels were not consistently challenged or cleared , and that visual welfare checks were therefore not always effective . The jury heard evidence that officers deliberately avoided opening blocked hatches to escape abuse from the prisoners then or later. In a prison environment where prisoners may be intoxicated, unconscious, self-harming, assaulted, or otherwise incapacitated behind a locked door, failure to maintain an unobstructed observation panel creates an obvious risk of late discovery and preventable 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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Delays in supplying material information relevant to death investigations and future-death prevention
Wider context from the report “Concern 12: Failure of state agencies to supply all information in a timely fashion.
In this Inquest I was presented with material information at the eleventh hour . Aside from being discourteous to the family and the Court such tardy provision has potential to frustrate a full investigation into the death and allow elements of care which may impact on future deaths to pass unnoticed .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to implement sufficient and sustained remedial action on identified prison safety concerns
Wider context from the report “Concern 11: Repeated systemic concerns at HMP Woodhill
Material before the court from oversight and inspection bodies demonstrated that concerns about drugs, safety, violence, self-isolation, observation panel compliance, ACCT weaknesses and welfare monitoring at HMP Woodhill had been identified over time. I am concerned that repeated identification of these issues has not resulted in sufficient or sustained remedial action , creating an ongoing risk of further deaths .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise IPP status as a material vulnerability requiring structured support and review
Wider context from the report “Concern 7: Particular vulnerability of prisoners serving IPP (Imprisonment for Public Protection) sentences
The evidence showed that prisoners serving IPP sentences may experience hopelessness, chronic frustration, deterioration in mental health and increased vulnerability to substance misuse and self-neglect . I am concerned that Mr Meikle's IPP status was not sufficiently recognised as a material risk factor requiring structured support, regular review and coordinated care .
” Open source report
20 Mar 2026 Luke Owen ASHCROFT · Prevention of Future Deaths report Greater Lincolnshire
View report summary
Concerns raised 2 Failure to ensure reliable telephone access after CSU cell lockdown View source Unsafe provision of corded telephones in cells occupied by prisoners who may self-harm View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Luke Owen ASHCROFT · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Luke Ashcroft was admitted to Lincoln County Hospital from HMP Lincoln after being found unconscious in his cell in the Care and Separation Unit. His death was confirmed on 1 July 2020, with the post-mortem finding hypoxic brain injury consistent with ligature application. The inquest identified concerns about missed healthcare opportunities, inadequate information sharing and risk mitigations, shortcomings in the ACCT plan, and failures to carry out required observations; it also raised concerns about the safety and availability of corded telephone access in the unit.
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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure reliable telephone access after CSU cell lockdown
Wider context from the report “My concerns are twofold.
Firstly, whilst not directly relevant to the death of Luke Ashcroft, I am concerned about the clear and obvious risks of self harm posed by the provision of a corded telephone, secured at one end, suspended at head height in a cell commonly occupied by prisoners, who may seek to self harm. I was told that the cell J109 had no ligature points and that the door was fitted with anti ligature fittings. As a consequence, that was the only method of securing telephone access. That same issue may extend to other cells in the CSU. Whether at head height or otherwise, the provision of a corded phone may well be an issue in potential cases of self harm and appears incongruous in comparison with other steps taken to ensure safety within that cell. The risks of an inmate utilising that cord in an act of self harm are self evident.
Secondly, the mechanism of provision of telephone access on CSU appears to require a prisoner requesting such provision before the cells are locked down . Thereafter, whilst a request can be made by a prisoner, telephone provision may depend upon the availability of additional officers to attend whilst the cell is unlocked and the telephone provided . That is not certain to take place. Given the proper availability to prisoners in crisis of freephone access to Samaritans and similar services, the possible absence of a handset to access such services is a matter of concern.
” 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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Unsafe provision of corded telephones in cells occupied by prisoners who may self-harm
Wider context from the report “My concerns are twofold.
Firstly, whilst not directly relevant to the death of Luke Ashcroft, I am concerned about the clear and obvious risks of self harm posed by the provision of a corded telephone, secured at one end, suspended at head height in a cell commonly occupied by prisoners, who may seek to self harm . I was told that the cell J109 had no ligature points and that the door was fitted with anti ligature fittings. As a consequence, that was the only method of securing telephone access. That same issue may extend to other cells in the CSU. Whether at head height or otherwise, the provision of a corded phone may well be an issue in potential cases of self harm and appears incongruous in comparison with other steps taken to ensure safety within that cell. The risks of an inmate utilising that cord in an act of self harm are self evident.
Secondly, the mechanism of provision of telephone access on CSU appears to require a prisoner requesting such provision before the cells are locked down. Thereafter, whilst a request can be made by a prisoner, telephone provision may depend upon the availability of additional officers to attend whilst the cell is unlocked and the telephone provided. That is not certain to take place. Given the proper availability to prisoners in crisis of freephone access to Samaritans and similar services, the possible absence of a handset to access such services is a matter of concern.
” Open source report
18 Mar 2026 Clare Louise Dupree · Prevention of Future Deaths report Avon
View report summary
Concerns raised 1 Failure to provide in-cell automatic fire detection across parts of the prison estate View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Clare Louise Dupree · 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
Clare Louise Dupree, aged 48, was taken into custody at HMP Eastwood Park and suffered smoke inhalation after a fire in her cell. The jury concluded that the lack of automatic in-cell fire detection delayed detection of the fire and resulted in her death; the use of external domestic smoke detectors possibly contributed to her 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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to provide in-cell automatic fire detection across parts of the prison estate
Wider context from the report “At the start of the inquest the MOJ made an admission it said …
1. “The Ministry of Justice has determined that in-cell automatic fire detection (AFD) is necessary to minimise the risk of harm from fires.
2. As at 26ᵗʰ December 2022, cell 59 on Residential 6 was not and is not currently equipped with in-cell AFD
3. For those cells which do not have in-cell AFD, battery powered standalone domestic smoke detectors (DSD’s) are in place outside cell doors, including cell 59 on Residential 6. This was the position as at 26ᵗʰ December 2022. The use of DSD’s as a mitigatory measure was agreed in 2015, in consultation with the Crown Premises Fire Safety Inspectorate. The Ministry of Justice acknowledges that the use of DSD’s in this way is a less effective way of minimising fire risks than in-cell AFD but has adopted them after thorough consideration as being the most effective available means of reducing risk as far as practicable until the installation of in-cell AFD can be completed “
During the inquest evidence was heard from ████████ from HMPPS - that in cell AFD's are now planned for Eastwood Park with a start date of June 2026 . I also heard about the position in relation to the prioritisation list for others in the prison estate. That said I also heard the frustration of ████████ from the CPFSI about the time this is taking to implement .
The matter of concern therefore … that in cell AFD is still to be implemented/completed at EWP prison and in addition a number of prisons across the prison estate. That the current use of DSD's only seek to mitigate the risks from an in-cell fire.
” Open source report
3 Mar 2026 Mujahid Adam · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 4 Failure to record 15-minute observations contemporaneously and accurately View source Lack of a clear definition and procedure for 15-minute observations View source Failure to maintain special cells in a condition that prevents access to ligature-making material View source Failure of daily accommodation and fabric checks to identify disrepair in special cells View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Mujahid Adam · 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
Mujahid Adam died by suicide after being found hanging in his prison cell on 15 March 2025; he was declared dead on 21 March 2025 at University College Hospital. The concerns included inadequate and non-contemporaneous recording of 15-minute observations, no clear definition of what constituted an observation, delays in calling Code Blue and cutting him down, and disrepair in the cell that allowed access to ligature material.
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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to record 15-minute observations contemporaneously and accurately
Wider context from the report “(a) The recording of observations of 15-minute checks is not contemporaneous and is prone to inaccuracy . It relies on a prison officer walking from the cell to the wing office to record observations, every 15 minutes, which may not be realistic if a prisoner has other duties to perform ;
” 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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear definition and procedure for 15-minute observations
Wider context from the report “(b) There is no clear definition of what constitutes an “observation” and how this should be done by staff at the prison when someone is on 15-minute observations ;
” 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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain special cells in a condition that prevents access to ligature-making material
Wider context from the report “(c) The cell occupied by Mr Adam is one of a handful of special cells in the prison which are used for vulnerable prisoners on constant watch or on 15-minute observation. It was in a state of disrepair and gave access to the hidden material from which a ligature could be made . Despite daily AFCs, that disrepair was not noted although this was a special cell.
” 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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure of daily accommodation and fabric checks to identify disrepair in special cells
Wider context from the report “(c) The cell occupied by Mr Adam is one of a handful of special cells in the prison which are used for vulnerable prisoners on constant watch or on 15-minute observation. It was in a state of disrepair and gave access to the hidden material from which a ligature could be made. Despite daily AFCs, that disrepair was not noted although this was a special cell .
” Open source report
17 Feb 2026 Edward James HANDS · Prevention of Future Deaths report Bedfordshire and Luton
View report summary
Concerns raised 5 Failure to recognise and escalate clinical deterioration View source Lack of frontline staff awareness of roles, responsibilities, response expectations and required paperwork for suspected illicit-substance influence View source Failure to observe and monitor prisoners suspected to be under the influence of illicit substances View source Failure to align policies and protocols for managing prisoners suspected to be under the influence of illicit substances View source Failure to arrange follow-up medical assessment when a prisoner's condition is not improving 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
Edward James HANDS · 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
Edward James Hands, known as Eddie, died in his cell at HMP Bedford on 16 February 2024 after consuming methadone and developing aspiration pneumonitis. The inquest identified failures in follow-up care, monitoring, escalation, and the implementation of the Under the Influence protocol, with confusion between prison and healthcare staff about their responsibilities.
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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise and escalate clinical deterioration
Wider context from the report “The evidence at the inquest revealed that the (primary) prison healthcare provider (within the prison) and prison staff are working to different policies and protocols in relation to those suspected to be ‘under the influence of illicit substances’; there is confusion and lack of awareness of those working in the prison as to the role and responsibilities and expectations about how to alert and manage a concern that a prisoner may be under the influence.
In this instance this confusion resulted in Eddie not being observed; had these checks and monitoring taken place, it would have been clear Eddie was not improving and that a follow up medical assessment was required. This meant his clinical deterioration was not recognised and escalated .
It is understood that the NHFT policy is designed to cover the entire Trust and may well, therefore, have relevance beyond Bedford prison. However, it is essential that the policy is clear on what happens when the individual institutions have their own local protocols. Eddie’s inquest has revealed how clarity on steps and paperwork required under the policy is essential amongst frontline staff to ensure the safest possible environment for prison residents at Bedford 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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Lack of frontline staff awareness of roles, responsibilities, response expectations and required paperwork for suspected illicit-substance influence
Wider context from the report “The evidence at the inquest revealed that the (primary) prison healthcare provider (within the prison) and prison staff are working to different policies and protocols in relation to those suspected to be ‘under the influence of illicit substances’; there is confusion and lack of awareness of those working in the prison as to the role and responsibilities and expectations about how to alert and manage a concern that a prisoner may be under the influence .
In this instance this confusion resulted in Eddie not being observed; had these checks and monitoring taken place, it would have been clear Eddie was not improving and that a follow up medical assessment was required. This meant his clinical deterioration was not recognised and escalated.
It is understood that the NHFT policy is designed to cover the entire Trust and may well, therefore, have relevance beyond Bedford prison. However, it is essential that the policy is clear on what happens when the individual institutions have their own local protocols. Eddie’s inquest has revealed how clarity on steps and paperwork required under the policy is essential amongst frontline staff to ensure the safest possible environment for prison residents at Bedford 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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to observe and monitor prisoners suspected to be under the influence of illicit substances
Wider context from the report “The evidence at the inquest revealed that the (primary) prison healthcare provider (within the prison) and prison staff are working to different policies and protocols in relation to those suspected to be ‘under the influence of illicit substances’; there is confusion and lack of awareness of those working in the prison as to the role and responsibilities and expectations about how to alert and manage a concern that a prisoner may be under the influence.
In this instance this confusion resulted in Eddie not being observed ; had these checks and monitoring taken place , it would have been clear Eddie was not improving and that a follow up medical assessment was required. This meant his clinical deterioration was not recognised and escalated.
It is understood that the NHFT policy is designed to cover the entire Trust and may well, therefore, have relevance beyond Bedford prison. However, it is essential that the policy is clear on what happens when the individual institutions have their own local protocols. Eddie’s inquest has revealed how clarity on steps and paperwork required under the policy is essential amongst frontline staff to ensure the safest possible environment for prison residents at Bedford 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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to align policies and protocols for managing prisoners suspected to be under the influence of illicit substances
Wider context from the report “The evidence at the inquest revealed that the (primary) prison healthcare provider (within the prison) and prison staff are working to different policies and protocols in relation to those suspected to be ‘under the influence of illicit substances’; there is confusion and lack of awareness of those working in the prison as to the role and responsibilities and expectations about how to alert and manage a concern that a prisoner may be under the influence.
In this instance this confusion resulted in Eddie not being observed; had these checks and monitoring taken place, it would have been clear Eddie was not improving and that a follow up medical assessment was required. This meant his clinical deterioration was not recognised and escalated.
It is understood that the NHFT policy is designed to cover the entire Trust and may well, therefore, have relevance beyond Bedford prison. However, it is essential that the policy is clear on what happens when the individual institutions have their own local protocols . Eddie’s inquest has revealed how clarity on steps and paperwork required under the policy is essential amongst frontline staff to ensure the safest possible environment for prison residents at Bedford 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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to arrange follow-up medical assessment when a prisoner's condition is not improving
Wider context from the report “The evidence at the inquest revealed that the (primary) prison healthcare provider (within the prison) and prison staff are working to different policies and protocols in relation to those suspected to be ‘under the influence of illicit substances’; there is confusion and lack of awareness of those working in the prison as to the role and responsibilities and expectations about how to alert and manage a concern that a prisoner may be under the influence.
In this instance this confusion resulted in Eddie not being observed; had these checks and monitoring taken place, it would have been clear Eddie was not improving and that a follow up medical assessment was required . This meant his clinical deterioration was not recognised and escalated.
It is understood that the NHFT policy is designed to cover the entire Trust and may well, therefore, have relevance beyond Bedford prison. However, it is essential that the policy is clear on what happens when the individual institutions have their own local protocols. Eddie’s inquest has revealed how clarity on steps and paperwork required under the policy is essential amongst frontline staff to ensure the safest possible environment for prison residents at Bedford Prison.
” Open source report
9 Feb 2026 Josh Yemi TARRANT · Prevention of Future Deaths report Kent and Medway
View report summary
Concerns raised 2 Lack of training for prison officers in relation to ABD View source Failure of prison officers who restrain prisoners to recognise ABD and treat it as a medical emergency View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Josh Yemi TARRANT · 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
Josh Yemi Tarrant died at HMP Elmley on 1 November 2023 after cocaine intoxication and a lengthy, challenging restraint while he was experiencing acute behavioural disturbance. The report raises concerns that acute behavioural disturbance was not recognised, that sufficient medical treatment was not provided at the earliest appropriate opportunity, and that prison staff lacked training to identify and respond to it.
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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Lack of training for prison officers in relation to ABD
Wider context from the report “HMPPS acknowledged that, despite this clear guidance, the Prison Service stopped teaching officers about ABD (aka ‘Excited Delirium’) in 2015 and have not taught it since then .
None of the officers who gave evidence in this inquest said that they had never been given any training in relation to ABD.
Dr████████ explained that ABD is a well-recognised condition. Indeed, SEAmb witnesses provided evidence in this inquest that, if their call handlers are told that a person is displaying signs of ABD whilst under restraint, the response would be upgraded to aa Category 1 response and the immediate despatch of a Critical Care Paramedic (“CCP”).
Dr████████ also stated that:
(1) Mr Tarrant was displaying ‘textbook’ signs of ABD which would have been apparent to a properly trained person within a matter of minutes;
(2) It was clearly a medical emergency that required the attendance of a CCP who would have provided sedation and other treatments;
(3) Had treatment been initiated at any time before 1 am Mr Tarrant probably would have survived.
I am concerned that:
(a) No training is provided to prison officers in relation to ABD (despite the clear advice of PSO 1600).
(b) If officers who are required to restrain prisoners remain unaware of ABD and the need to treat it as a medical emergency, then further deaths are likely in future.
Accordingly, this situation should be reviewed and consideration given as to whether any steps should be taken to reduce the risk of death by from ABD. In particular, training should be reviewed and assessed by the Prison Service with assistance from appropriately qualified clinicians.
” 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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure of prison officers who restrain prisoners to recognise ABD and treat it as a medical emergency
Wider context from the report “HMPPS acknowledged that, despite this clear guidance, the Prison Service stopped teaching officers about ABD (aka ‘Excited Delirium’) in 2015 and have not taught it since then.
None of the officers who gave evidence in this inquest said that they had never been given any training in relation to ABD.
Dr████████ explained that ABD is a well-recognised condition. Indeed, SEAmb witnesses provided evidence in this inquest that, if their call handlers are told that a person is displaying signs of ABD whilst under restraint, the response would be upgraded to aa Category 1 response and the immediate despatch of a Critical Care Paramedic (“CCP”).
Dr████████ also stated that:
(1) Mr Tarrant was displaying ‘textbook’ signs of ABD which would have been apparent to a properly trained person within a matter of minutes;
(2) It was clearly a medical emergency that required the attendance of a CCP who would have provided sedation and other treatments;
(3) Had treatment been initiated at any time before 1 am Mr Tarrant probably would have survived.
I am concerned that:
(a) No training is provided to prison officers in relation to ABD (despite the clear advice of PSO 1600).
(b) If officers who are required to restrain prisoners remain unaware of ABD and the need to treat it as a medical emergency , then further deaths are likely in future .
Accordingly, this situation should be reviewed and consideration given as to whether any steps should be taken to reduce the risk of death by from ABD. In particular, training should be reviewed and assessed by the Prison Service with assistance from appropriately qualified clinicians.
” Open source report
9 Feb 2026 Gareth Chumber-Kelly · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 4 Inefficiency and slowness of the prison reception process View source Failure to provide suicide and self-harm risk management training to prison officers View source Failure to provide regular mandatory basic life support training to prison officers View source Failure to retain documentation accompanying prisoners during reception View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Gareth Chumber-Kelly · 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
Gareth Chumber-Kelly died after hanging himself while in custody at HMP Pentonville on 17 July 2023. The report identified concerns about lost or incomplete transfer documentation, inadequate recognition and management of suicide and self-harm risks, insufficient staff training, failures to provide basic life support, and inadequate staffing and support during crucial periods.
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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Inefficiency and slowness of the prison reception process
Wider context from the report “(1) The court heard evidence from prison staff that the reception process at HMP Pentonville was inefficient and slow and that paperwork would be sometimes be lost. This creates a risk to the safety and well-being of prisoners as the documentation accompanying the prisoner as they are conveyed to prison may contain (as was the case with Mr Chumber-Kelly) very important information about the prisoners which is relevant to ensuring all appropriate steps and measures are put in place to protect them. The Governor at HMP Pentonville told the court that no steps have been taken to address this recurrent problem , and the risk of important documentation being lost, and there has been no dialogue with Serco to address this issue.
” 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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to provide suicide and self-harm risk management training to prison officers
Wider context from the report “(2) The court heard evidence that 2 prisoners had died by ligature suspension (on 17.6.2021 and 1.3.22) prior to Mr Chumber-Kelly’s death, and that since then a further 5 prisoners have died by ligature suspension (one of which was Mr Chumber-Kelly). The Governor of HMP Pentonville told the court that Suicide and Self harm training for prison staff had been suspended during Covid and had never been re-started notwithstanding that 38% of prisoners arriving at HMP Pentonville said they felt suicidal and notwithstanding that 7 prisoners have died by ligature suspension since June 2021. The failure to train prison officers in the risks and management of suicide and self-harm creates a risk of future deaths .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to provide regular mandatory basic life support training to prison officers
Wider context from the report “(3) The court heard evidence that the first two officers on the scene failed to provide any form of basic life support despite having received training on how to do so. Both officers described how they panicked and did not know what to do. The court heard evidence from a consultant paramedic from the London Ambulance service with extensive experience in resuscitation who explained that for every minute without CPR there is a 10-22% drop in survival rates. It is critically important that the first person on the scene in such emergency situations (who will almost always be the prison officers) are properly and regularly trained in basic life support so that they are able to render such aid immediately on arrival. The Governor of the prison told the court that no refresher CPR training had been provided to prison staff since 2023 notwithstanding the 5 deaths of prisoners by ligature suspension that have occurred since. This is deeply concerning given that this very same issue was raised in a Prevention of Future Deaths Report by Mary Hassell, HM Senior Coroner of Inner North London on 18th September 2023 relating to the death of Amarjit Singh and yet in the 2 years since that PFD was issued there is still no mandatory basic life support training for prison officers .
The failure of the prison to provide regular, mandatory basic life support to all prison officer creates a risk of future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to retain documentation accompanying prisoners during reception
Wider context from the report “(1) The court heard evidence from prison staff that the reception process at HMP Pentonville was inefficient and slow and that paperwork would be sometimes be lost . This creates a risk to the safety and well-being of prisoners as the documentation accompanying the prisoner as they are conveyed to prison may contain (as was the case with Mr Chumber-Kelly) very important information about the prisoners which is relevant to ensuring all appropriate steps and measures are put in place to protect them. The Governor at HMP Pentonville told the court that no steps have been taken to address this recurrent problem, and the risk of important documentation being lost , and there has been no dialogue with Serco to address this issue.
” Open source report
6 Feb 2026 Paul Christopher THOMPSON · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 3 Shortcomings in internal information passage concerning the release of prisoners receiving mental health care View source Failure to provide released prisoners with clear information about when to report to Probation Services View source Failure to provide Probation Services with timely release information View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Paul Christopher THOMPSON · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Paul Christopher THOMPSON died on 15 July 2024 after moving onto the railway tracks at Elmswell Railway Station and lying in the path of an oncoming freight train. He had a history of suicidal ideation and had been receiving mental health care in custody. The report identified shortcomings in the internal passage of information at HMP Norwich about the release of prisoners receiving mental health care, and in the timely provision of release information to Probation Services.
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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Shortcomings in internal information passage concerning the release of prisoners receiving mental health care
Wider context from the report “The evidence received at Inquest indicated that inadequate arrangements existed at HMP Norwich to provide for the release of prisoners in receipt of mental health care during out of hours periods .
In line with procedures in place at HMP Norwich, Mr. Thompson should have been seen by the mental health team treating him so that appropriate arrangements could be put in place for follow up care and treatment in the community.
This did not occur.
The mental health team treating Mr. Thompson were only made aware of the fact that he had been released when it was mentioned the following day during a general staff briefing .
In addition, Mr. Thompson was not given clear information around when to report to Probation Services, nor were Probation Services advised in a timely manner of Mr. Thompson’s release. As a consequence, when Mr. Thompson presented to Durham Probation Office the day after his release (12th July 2024), staff at the Probation Office in Durham had no knowledge of him or the fact of his release.
Neither the failure to properly out-process Mr. Thompson from mental health services at HMP Norwich, nor the failure to inform Probation Services in Durham of Mr. Thompson’s release made a material contribution to his death.
However, I am concerned that the evidence heard at Mr. Thompson’s Inquest reveals shortcomings in the internal passage of information at HMP Norwich concerning the release of prisoners in receipt of mental health care and treatment, particularly those who have expressed recent suicidal ideation . In addition, I am concerned as to the adequacy of information passage to the Probation Service relating to the release of prisoners from custody.
In another case these failures may give rise to a risk of 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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to provide released prisoners with clear information about when to report to Probation Services
Wider context from the report “The evidence received at Inquest indicated that inadequate arrangements existed at HMP Norwich to provide for the release of prisoners in receipt of mental health care during out of hours periods.
In line with procedures in place at HMP Norwich, Mr. Thompson should have been seen by the mental health team treating him so that appropriate arrangements could be put in place for follow up care and treatment in the community.
This did not occur.
The mental health team treating Mr. Thompson were only made aware of the fact that he had been released when it was mentioned the following day during a general staff briefing.
In addition, Mr. Thompson was not given clear information around when to report to Probation Services , nor were Probation Services advised in a timely manner of Mr. Thompson’s release. As a consequence, when Mr. Thompson presented to Durham Probation Office the day after his release (12th July 2024), staff at the Probation Office in Durham had no knowledge of him or the fact of his release.
Neither the failure to properly out-process Mr. Thompson from mental health services at HMP Norwich, nor the failure to inform Probation Services in Durham of Mr. Thompson’s release made a material contribution to his death.
However, I am concerned that the evidence heard at Mr. Thompson’s Inquest reveals shortcomings in the internal passage of information at HMP Norwich concerning the release of prisoners in receipt of mental health care and treatment, particularly those who have expressed recent suicidal ideation. In addition, I am concerned as to the adequacy of information passage to the Probation Service relating to the release of prisoners from custody.
In another case these failures may give rise to a risk of 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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to provide Probation Services with timely release information
Wider context from the report “The evidence received at Inquest indicated that inadequate arrangements existed at HMP Norwich to provide for the release of prisoners in receipt of mental health care during out of hours periods.
In line with procedures in place at HMP Norwich, Mr. Thompson should have been seen by the mental health team treating him so that appropriate arrangements could be put in place for follow up care and treatment in the community.
This did not occur.
The mental health team treating Mr. Thompson were only made aware of the fact that he had been released when it was mentioned the following day during a general staff briefing.
In addition, Mr. Thompson was not given clear information around when to report to Probation Services, nor were Probation Services advised in a timely manner of Mr. Thompson’s release . As a consequence, when Mr. Thompson presented to Durham Probation Office the day after his release (12th July 2024), staff at the Probation Office in Durham had no knowledge of him or the fact of his release .
Neither the failure to properly out-process Mr. Thompson from mental health services at HMP Norwich, nor the failure to inform Probation Services in Durham of Mr. Thompson’s release made a material contribution to his death.
However, I am concerned that the evidence heard at Mr. Thompson’s Inquest reveals shortcomings in the internal passage of information at HMP Norwich concerning the release of prisoners in receipt of mental health care and treatment, particularly those who have expressed recent suicidal ideation. In addition, I am concerned as to the adequacy of information passage to the Probation Service relating to the release of prisoners from custody .
In another case these failures may give rise to a risk of death.
” Open source report
6 Feb 2026 Emmett Peter MORRISON · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 2 Continued influx of illicit drugs into HMP Long Lartin View source Failure to record and implement support actions in ACCT care plans View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Emmett Peter MORRISON · 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
Emmett Peter Morrison, a serving prisoner at HMP Long Lartin, was found suspended by a ligature in his cell on 13 October 2024 and died from his injuries at hospital on 16 October 2024. The report raised concerns about the continued influx of illicit drugs into the prison and failures to record support actions in ACCT care plans and arrange a further ACCT review sooner.
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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Continued influx of illicit drugs into HMP Long Lartin
Wider context from the report “1) Continued influx of drugs into HMP Long Lartin
Throughout Emmett’s time at HMP Long Lartin, and at the time of his death, the influx of illicit drugs into the prison was a major problem . HMP Long Lartin is a high security prison, a large proportion of whose inmates are serving lengthy sentences. The demand for, supply and distribution of drugs within the prison is therefore capable of causing significant disruption to its security and stability, as well as posing significant risk to the wellbeing of prisoners and staff working there.
Staff at the prison are doing all they can to try to reduce the demand for these drugs, and to assist those dependent on them, but their job is being made considerably harder by the continued and steady flow of illicit substances into the prison .
I have been told in evidence that HMP Long Lartin has been identified as one of the two prisons in the country with the biggest issues in this regard.
I have also heard evidence that measures put in place since Emmett’s death have reduced the number of drone drops of drugs into the prison, and that funding is now in place to install grilles on windows at the prison to prevent prisoners reaching out to retrieve drugs from those drones, although that work is yet to be carried out.
Those involved in the supply of drugs within the prison are often part of highly sophisticated organised crime groups, and unless proper measures are put in place at the prison, its regime and the welfare of its staff and prisoners will continue to be placed at risk as the influx of drugs continues .
Class A drugs, which continue to be used within the prison, present a clear and obvious risk to the lives of those who use them.
Novel Psychoactive Substances, like Spice, the make-up of which can change from batch to batch and makes detection problematic, and whose effects can be both unpredictable and life-threatening, as was apparent in EM’s case, also remain prevalent throughout 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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to record and implement support actions in ACCT care plans
Wider context from the report “2) Failures in ACCT process
Emmett was a prisoner with a considerable history of substance misuse and self-harm while in custody.
Of the eight ACCT reviews which were conducted after Emmett's ACCT document was re-opened on 10.9.24, not one resulted in any support actions being entered onto the ACCT care plan .
The ACCT care plan is a key part of the ACCT process, which requires those taking part in ACCT case reviews to set in train actions designed to reduce the prisoner’s risk of suicide or self-harm. As the guidance then in force made plain, it is a mandatory part of the ACCT process.
The reasons given by staff who took part in these ACCT reviews for not having done this included:
(i) being sure that they had talked about it, but had not noted anything down ;
(ii) thinking that, if EM didn’t attend an ACCT review, they couldn’t put any actions in place because that could only be done with his agreement; and
(iii) they were so weighed down by the number of ACCT reviews which they had to carry out and the rest of their workload, that they simply had no time to complete this part of the review.
Most worryingly, two of those witnesses who cited a heavy workload and pressures of work for Care Plans not being completed, made clear that not only this was commonplace at the time of these events but also that it is still an issue .
Despite hearing evidence that measures have been put in place to train officers conducting ACCT reviews, and to conduct Quality Assurance checks on open ACCT documents, I was left with the clear impression that ACCT Care Plans are still being overlooked .
I also note that as long ago as 2021 this court heard an inquest into the death of a prisoner at the same prison in 2018, following which I wrote a Prevention of Future Deaths report to the then Governing Governor of the prison, indicating my concern that ACCT Case Reviews for that prisoner had, on several occasions, failed to review or add actions to the ACCT Care Plan . It is therefore a concern that, 6 years on from that prisoner's death, the same issue arose in Emmett's case.
As long as that remains the case, the lives of those vulnerable prisoners whom the ACCT process is designed to protect will continue to be put at risk.
” Open source report
Concerns raised 2 Failure to protect prisoners convicted of sexual offences from bullying, verbal abuse and threats View source Failure to prevent offence-neutral residential integration of prisoners convicted of sexual offences View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Nigel Anthony FECKEY · 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
Nigel Anthony Feckey was found suspended by a ligature in his prison cell at HMP Fosse Way on 23 September 2024 and was declared deceased at the scene. The inquest concluded suicide, with concerns including bullying and abuse of prisoners convicted of sexual offences, offence-neutral prison arrangements, staffing pressures, weaknesses in information-sharing and ACCT processes, and failures to respond adequately to reported concerns and risks.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to protect prisoners convicted of sexual offences from bullying, verbal abuse and threats
Wider context from the report “Mr Feckey was a Prisoner Convicted of a sexual offence (PCOSO).
Offence Neutrality is when there is no special block to keep sex offenders in, and the population is mingled regardless of the offence they are in prison for. It was discussed at the inquest and concluded in evidence that it is not possible to keep offences secret for the most part because although the prisoners have access to the wide internet themselves in their cells, they only have to ask someone on the phone or at a visit to find out what someone is in for and it can be that easy. Also heard at the inquest was that many mainstream prisoners held strong views that they did not wish to share their living space with men convicted of sex offences. They were both vocal and physical in their resistance to integrated living. The data at Fosse Way suggested that a change was required as figures for self-harm and self-isolation were beginning to emerge. Although steps were taken to encourage integration a reassessment of this position took place in early 2025 and decision was made to separate the residential houseblocks and In March 2025 700 prisoners from the prison were transferred to a non-integrated unit. Since then, there had been a reduction in the number of ACCT documents and self-isolation.
Evidence in the inquest indicated that sex offender prisoners were scared, they felt they couldn’t leave their cells and that they were vulnerable to direct bullying or verbal abuse. Shouting and threats were constantly heard directly connected to the PCOSO offences.
Whilst Fosse Way have taken their own risk reductions regarding offence neutrality, I understand that the policy remains and is still implemented in other prisons and it is a matter of concern to me that a future death may occur.
” 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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent offence-neutral residential integration of prisoners convicted of sexual offences
Wider context from the report “Mr Feckey was a Prisoner Convicted of a sexual offence (PCOSO).
Offence Neutrality is when there is no special block to keep sex offenders in, and the population is mingled regardless of the offence they are in prison for. It was discussed at the inquest and concluded in evidence that it is not possible to keep offences secret for the most part because although the prisoners have access to the wide internet themselves in their cells, they only have to ask someone on the phone or at a visit to find out what someone is in for and it can be that easy. Also heard at the inquest was that many mainstream prisoners held strong views that they did not wish to share their living space with men convicted of sex offences. They were both vocal and physical in their resistance to integrated living. The data at Fosse Way suggested that a change was required as figures for self-harm and self-isolation were beginning to emerge. Although steps were taken to encourage integration a reassessment of this position took place in early 2025 and decision was made to separate the residential houseblocks and In March 2025 700 prisoners from the prison were transferred to a non-integrated unit. Since then, there had been a reduction in the number of ACCT documents and self-isolation.
Evidence in the inquest indicated that sex offender prisoners were scared, they felt they couldn’t leave their cells and that they were vulnerable to direct bullying or verbal abuse. Shouting and threats were constantly heard directly connected to the PCOSO offences.
Whilst Fosse Way have taken their own risk reductions regarding offence neutrality, I understand that the policy remains and is still implemented in other prisons and it is a matter of concern to me that a future death may occur.
” Open source report
12 Jan 2026 STUART CHRISTOPHER JAMES BERRY · Prevention of Future Deaths report Essex
View report summary
Concerns raised 14 Failure to share critical suicide-risk information with prison staff View source Failure of liaison with external specialist substance misuse services View source Failure of internal multidisciplinary joint working View source Failure to update and document risk assessments View source Failure to document self-harm and suicide risk in clinical records View source Failure in HCRG staff training View source Failure to update and document care plans View source Failure to make urgent mental health referrals View source Failure of HCRG monitoring, supervision and quality assurance View source Failure of CMHT and Care Coordinator performance under the Care Programme Approach View source Failure to communicate with families and gather collateral information View source Inadequate national prison officer training for suicide risk assessment View source Failure to cost structural mitigation of accessible window-bar ligature points View source Inadequate electronic record documentation View source See 11 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
STUART CHRISTOPHER JAMES BERRY · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
STUART CHRISTOPHER JAMES BERRY, who had a history of mental health issues and significant cocaine misuse, was remanded to HMP Chelmsford on 27 January 2024 after expressing an intention to end his life. He was found suspended in his cell about seven hours after arrival and died at Broomfield Hospital on 1 February 2024; the medical cause of death was hanging and the jury concluded suicide. The principal concerns included failures in mental-health care, communication and risk documentation, failure to share information about his extreme suicide risk, inadequate assessment and supervision in prison, and the accessibility of cell-window ligature points.
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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to share critical suicide-risk information with prison staff
Wider context from the report “In addition to failing to share crucial and obviously relevant information regarding Mr Berry’s extreme risk of suicide provided by the CPN at Court with prison staff , the jury found that the reception nurse, in the context of the clear information known to her, failed to: (a) document his risk of self-harm and suicide in the Systm One records and (b) failed to refer Mr Berry, that day, for an urgent review by the Mental Health team.
CONCERN: Such comprehensive shortcomings in performance in respect of information sharing , conduct of assessments, basic documentation and escalation/referral on to relevant colleagues indicates (a) a failure in training of a very concerning kind, alongside (b) a failure in HCRG monitoring of standards, supervision and quality assurance processes to identify and address such extensive failures in performance.
” 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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure of liaison with external specialist substance misuse services
Wider context from the report “CONCERN: During Mr Berry’s inquest, once again, many of the continuing failings under precisely the themes identified in the 2024 ‘Thematic Review’ and in PFDR responses prior to that review as well as in the period since that Review, have been identified as having informed the causative features contributing to the death of a patient under EPUT’s care. In my opinion, the actions taken by EPUT to date to address the acknowledged failings reflected under the themes and issues referred to above have been, and remain, inadequate and incomplete, specifically:
(a) Failures in the performance of the CMHT and the allocated Care Coordinator as required under the Care Programme Approach (CPA) and as mandated by EPUT policy. These failures indicated significant human error not detected by an insufficiently robust system and not therefore corrected prior to the death:
(b) Failures in Care Planning: specifically, a failure to appropriately up-date and document matters relating to Mr Berry’s Care Plan consistent with Trust policy.
(c) Failures in Risk Assessments: specifically, failures to appropriately up-date and document matters relating to Mr Berry’s risk assessment consistent with Trust policy.
(d) Failures in Documentation: in a number of acknowledged respects the electronic records were inadequate - and inconsistent with EPUT policy.
(e) Failure of joint working internally: the CC did not attempt to escalate or consult with EPUT colleagues via the regular weekly MTD meeting or any other type of Professionals’ Meeting.
(f) Failure of joint working externally : the CC did not liaise at all with the external specialist substance misuse team , even though the cocaine misuse was a central aspect of his presentation and mental health deterioration.
(g) Failures in Communication within and between teams as above but also, crucially, including a failure to appropriately liaise with the deceased’s Family to gather collateral information and to provide a carer’s assessment and/or support to Mr Berry’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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure of internal multidisciplinary joint working
Wider context from the report “CONCERN: During Mr Berry’s inquest, once again, many of the continuing failings under precisely the themes identified in the 2024 ‘Thematic Review’ and in PFDR responses prior to that review as well as in the period since that Review, have been identified as having informed the causative features contributing to the death of a patient under EPUT’s care. In my opinion, the actions taken by EPUT to date to address the acknowledged failings reflected under the themes and issues referred to above have been, and remain, inadequate and incomplete, specifically:
(a) Failures in the performance of the CMHT and the allocated Care Coordinator as required under the Care Programme Approach (CPA) and as mandated by EPUT policy. These failures indicated significant human error not detected by an insufficiently robust system and not therefore corrected prior to the death:
(b) Failures in Care Planning: specifically, a failure to appropriately up-date and document matters relating to Mr Berry’s Care Plan consistent with Trust policy.
(c) Failures in Risk Assessments: specifically, failures to appropriately up-date and document matters relating to Mr Berry’s risk assessment consistent with Trust policy.
(d) Failures in Documentation: in a number of acknowledged respects the electronic records were inadequate - and inconsistent with EPUT policy.
(e) Failure of joint working internally : the CC did not attempt to escalate or consult with EPUT colleagues via the regular weekly MTD meeting or any other type of Professionals’ Meeting.
(f) Failure of joint working externally: the CC did not liaise at all with the external specialist substance misuse team, even though the cocaine misuse was a central aspect of his presentation and mental health deterioration.
(g) Failures in Communication within and between teams as above but also, crucially, including a failure to appropriately liaise with the deceased’s Family to gather collateral information and to provide a carer’s assessment and/or support to Mr Berry’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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to update and document risk assessments
Wider context from the report “CONCERN: During Mr Berry’s inquest, once again, many of the continuing failings under precisely the themes identified in the 2024 ‘Thematic Review’ and in PFDR responses prior to that review as well as in the period since that Review, have been identified as having informed the causative features contributing to the death of a patient under EPUT’s care. In my opinion, the actions taken by EPUT to date to address the acknowledged failings reflected under the themes and issues referred to above have been, and remain, inadequate and incomplete, specifically:
(a) Failures in the performance of the CMHT and the allocated Care Coordinator as required under the Care Programme Approach (CPA) and as mandated by EPUT policy. These failures indicated significant human error not detected by an insufficiently robust system and not therefore corrected prior to the death:
(b) Failures in Care Planning: specifically, a failure to appropriately up-date and document matters relating to Mr Berry’s Care Plan consistent with Trust policy.
(c) Failures in Risk Assessments: specifically, failures to appropriately up-date and document matters relating to Mr Berry’s risk assessment consistent with Trust policy .
(d) Failures in Documentation: in a number of acknowledged respects the electronic records were inadequate - and inconsistent with EPUT policy.
(e) Failure of joint working internally: the CC did not attempt to escalate or consult with EPUT colleagues via the regular weekly MTD meeting or any other type of Professionals’ Meeting.
(f) Failure of joint working externally: the CC did not liaise at all with the external specialist substance misuse team, even though the cocaine misuse was a central aspect of his presentation and mental health deterioration.
(g) Failures in Communication within and between teams as above but also, crucially, including a failure to appropriately liaise with the deceased’s Family to gather collateral information and to provide a carer’s assessment and/or support to Mr Berry’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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to document self-harm and suicide risk in clinical records
Wider context from the report “In addition to failing to share crucial and obviously relevant information regarding Mr Berry’s extreme risk of suicide provided by the CPN at Court with prison staff, the jury found that the reception nurse, in the context of the clear information known to her, failed to: (a) document his risk of self-harm and suicide in the Systm One records and (b) failed to refer Mr Berry, that day, for an urgent review by the Mental Health team.
CONCERN: Such comprehensive shortcomings in performance in respect of information sharing, conduct of assessments, basic documentation and escalation/referral on to relevant colleagues indicates (a) a failure in training of a very concerning kind, alongside (b) a failure in HCRG monitoring of standards, supervision and quality assurance processes to identify and address such extensive failures in performance.
” 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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure in HCRG staff training
Wider context from the report “In addition to failing to share crucial and obviously relevant information regarding Mr Berry’s extreme risk of suicide provided by the CPN at Court with prison staff, the jury found that the reception nurse, in the context of the clear information known to her, failed to: (a) document his risk of self-harm and suicide in the Systm One records and (b) failed to refer Mr Berry, that day, for an urgent review by the Mental Health team.
CONCERN: Such comprehensive shortcomings in performance in respect of information sharing, conduct of assessments, basic documentation and escalation/referral on to relevant colleagues indicates (a) a failure in training of a very concerning kind , alongside (b) a failure in HCRG monitoring of standards, supervision and quality assurance processes to identify and address such extensive failures in performance.
” 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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to update and document care plans
Wider context from the report “CONCERN: During Mr Berry’s inquest, once again, many of the continuing failings under precisely the themes identified in the 2024 ‘Thematic Review’ and in PFDR responses prior to that review as well as in the period since that Review, have been identified as having informed the causative features contributing to the death of a patient under EPUT’s care. In my opinion, the actions taken by EPUT to date to address the acknowledged failings reflected under the themes and issues referred to above have been, and remain, inadequate and incomplete, specifically:
(a) Failures in the performance of the CMHT and the allocated Care Coordinator as required under the Care Programme Approach (CPA) and as mandated by EPUT policy. These failures indicated significant human error not detected by an insufficiently robust system and not therefore corrected prior to the death:
(b) Failures in Care Planning: specifically, a failure to appropriately up-date and document matters relating to Mr Berry’s Care Plan consistent with Trust policy .
(c) Failures in Risk Assessments: specifically, failures to appropriately up-date and document matters relating to Mr Berry’s risk assessment consistent with Trust policy.
(d) Failures in Documentation: in a number of acknowledged respects the electronic records were inadequate - and inconsistent with EPUT policy.
(e) Failure of joint working internally: the CC did not attempt to escalate or consult with EPUT colleagues via the regular weekly MTD meeting or any other type of Professionals’ Meeting.
(f) Failure of joint working externally: the CC did not liaise at all with the external specialist substance misuse team, even though the cocaine misuse was a central aspect of his presentation and mental health deterioration.
(g) Failures in Communication within and between teams as above but also, crucially, including a failure to appropriately liaise with the deceased’s Family to gather collateral information and to provide a carer’s assessment and/or support to Mr Berry’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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to make urgent mental health referrals
Wider context from the report “In addition to failing to share crucial and obviously relevant information regarding Mr Berry’s extreme risk of suicide provided by the CPN at Court with prison staff, the jury found that the reception nurse, in the context of the clear information known to her, failed to: (a) document his risk of self-harm and suicide in the Systm One records and (b) failed to refer Mr Berry, that day, for an urgent review by the Mental Health team .
CONCERN: Such comprehensive shortcomings in performance in respect of information sharing, conduct of assessments, basic documentation and escalation/referral on to relevant colleagues indicates (a) a failure in training of a very concerning kind, alongside (b) a failure in HCRG monitoring of standards, supervision and quality assurance processes to identify and address such extensive failures in performance.
” 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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure of HCRG monitoring, supervision and quality assurance
Wider context from the report “In addition to failing to share crucial and obviously relevant information regarding Mr Berry’s extreme risk of suicide provided by the CPN at Court with prison staff, the jury found that the reception nurse, in the context of the clear information known to her, failed to: (a) document his risk of self-harm and suicide in the Systm One records and (b) failed to refer Mr Berry, that day, for an urgent review by the Mental Health team.
CONCERN: Such comprehensive shortcomings in performance in respect of information sharing, conduct of assessments, basic documentation and escalation/referral on to relevant colleagues indicates (a) a failure in training of a very concerning kind, alongside (b) a failure in HCRG monitoring of standards, supervision and quality assurance processes to identify and address such extensive failures in performance.
” 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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure of CMHT and Care Coordinator performance under the Care Programme Approach
Wider context from the report “CONCERN: During Mr Berry’s inquest, once again, many of the continuing failings under precisely the themes identified in the 2024 ‘Thematic Review’ and in PFDR responses prior to that review as well as in the period since that Review, have been identified as having informed the causative features contributing to the death of a patient under EPUT’s care. In my opinion, the actions taken by EPUT to date to address the acknowledged failings reflected under the themes and issues referred to above have been, and remain, inadequate and incomplete, specifically:
(a) Failures in the performance of the CMHT and the allocated Care Coordinator as required under the Care Programme Approach (CPA) and as mandated by EPUT policy. These failures indicated significant human error not detected by an insufficiently robust system and not therefore corrected prior to the death :
(b) Failures in Care Planning: specifically, a failure to appropriately up-date and document matters relating to Mr Berry’s Care Plan consistent with Trust policy.
(c) Failures in Risk Assessments: specifically, failures to appropriately up-date and document matters relating to Mr Berry’s risk assessment consistent with Trust policy.
(d) Failures in Documentation: in a number of acknowledged respects the electronic records were inadequate - and inconsistent with EPUT policy.
(e) Failure of joint working internally: the CC did not attempt to escalate or consult with EPUT colleagues via the regular weekly MTD meeting or any other type of Professionals’ Meeting.
(f) Failure of joint working externally: the CC did not liaise at all with the external specialist substance misuse team, even though the cocaine misuse was a central aspect of his presentation and mental health deterioration.
(g) Failures in Communication within and between teams as above but also, crucially, including a failure to appropriately liaise with the deceased’s Family to gather collateral information and to provide a carer’s assessment and/or support to Mr Berry’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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate with families and gather collateral information
Wider context from the report “CONCERN: During Mr Berry’s inquest, once again, many of the continuing failings under precisely the themes identified in the 2024 ‘Thematic Review’ and in PFDR responses prior to that review as well as in the period since that Review, have been identified as having informed the causative features contributing to the death of a patient under EPUT’s care. In my opinion, the actions taken by EPUT to date to address the acknowledged failings reflected under the themes and issues referred to above have been, and remain, inadequate and incomplete, specifically:
(a) Failures in the performance of the CMHT and the allocated Care Coordinator as required under the Care Programme Approach (CPA) and as mandated by EPUT policy. These failures indicated significant human error not detected by an insufficiently robust system and not therefore corrected prior to the death:
(b) Failures in Care Planning: specifically, a failure to appropriately up-date and document matters relating to Mr Berry’s Care Plan consistent with Trust policy.
(c) Failures in Risk Assessments: specifically, failures to appropriately up-date and document matters relating to Mr Berry’s risk assessment consistent with Trust policy.
(d) Failures in Documentation: in a number of acknowledged respects the electronic records were inadequate - and inconsistent with EPUT policy.
(e) Failure of joint working internally: the CC did not attempt to escalate or consult with EPUT colleagues via the regular weekly MTD meeting or any other type of Professionals’ Meeting.
(f) Failure of joint working externally: the CC did not liaise at all with the external specialist substance misuse team, even though the cocaine misuse was a central aspect of his presentation and mental health deterioration.
(g) Failures in Communication within and between teams as above but also, crucially, including a failure to appropriately liaise with the deceased’s Family to gather collateral information and to provide a carer’s assessment and/or support to Mr Berry’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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Inadequate national prison officer training for suicide risk assessment
Wider context from the report “CONCERN: In the context of the finding of the jury of a gross failure to ensure that Mr Berry was, in all the circumstances as known to the prison staff, subject to Constant Supervision, I am concerned that inadequate national training contributed to an over-reliance by prison staff on the subjective perception of an ‘improvement’ in a prisoner’s transient presentation and demeanour over obvious and grave documented risk factors when assessing risk and setting observation levels. The reassurance provided by Mr Berry, (according to the Supervising Officer) appears to have been dangerously misleading and uncritically accepted notwithstanding the clear, high risk of suicide Mr Berry presented. This, in turn, gives rise to my concern (in the light of the evidence provided by the POELT trainer) that the exceptionally short time allocated in national prison officer training to equip officers with the requisite skills to assess, identify and records triggers, risk factors and protective factors is wholly inadequate.
” 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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to cost structural mitigation of accessible window-bar ligature points
Wider context from the report “CONCERN: A further concern raised by the evidence relates to the lack of any attempt to cost structural cell improvements to mitigate , at least in some cells on each wing, the most obvious of ligature points in the Victorian Prison estates’ cells, namely the readily accessible fixed bars at the windows. Whilst other less obvious ligature points are potentially available in cells, all the (multiple) self-inflicted ligature related deaths at HMP Chelmsford in recent years have exclusively involved the use of the window bars.
The HMPPS Prison Group Director for Hertfordshire, Essex and Suffolk prisons undertook, following his evidence that such costings had not even been sought to date, to now ensure that such an exercise is undertaken. However, the concern remains that this is a national issue in relation to all Victorian or equivalent prisons and that absent even a costing exercise, steps to mitigate this serious, obvious and continuing risk will not be addressed .
” 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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Inadequate electronic record documentation
Wider context from the report “CONCERN: During Mr Berry’s inquest, once again, many of the continuing failings under precisely the themes identified in the 2024 ‘Thematic Review’ and in PFDR responses prior to that review as well as in the period since that Review, have been identified as having informed the causative features contributing to the death of a patient under EPUT’s care. In my opinion, the actions taken by EPUT to date to address the acknowledged failings reflected under the themes and issues referred to above have been, and remain, inadequate and incomplete, specifically:
(a) Failures in the performance of the CMHT and the allocated Care Coordinator as required under the Care Programme Approach (CPA) and as mandated by EPUT policy. These failures indicated significant human error not detected by an insufficiently robust system and not therefore corrected prior to the death:
(b) Failures in Care Planning: specifically, a failure to appropriately up-date and document matters relating to Mr Berry’s Care Plan consistent with Trust policy.
(c) Failures in Risk Assessments: specifically, failures to appropriately up-date and document matters relating to Mr Berry’s risk assessment consistent with Trust policy.
(d) Failures in Documentation: in a number of acknowledged respects the electronic records were inadequate - and inconsistent with EPUT policy.
(e) Failure of joint working internally: the CC did not attempt to escalate or consult with EPUT colleagues via the regular weekly MTD meeting or any other type of Professionals’ Meeting.
(f) Failure of joint working externally: the CC did not liaise at all with the external specialist substance misuse team, even though the cocaine misuse was a central aspect of his presentation and mental health deterioration.
(g) Failures in Communication within and between teams as above but also, crucially, including a failure to appropriately liaise with the deceased’s Family to gather collateral information and to provide a carer’s assessment and/or support to Mr Berry’s family.
” Open source report
15 Dec 2025 Sundeep Ghuman · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 7 Failure to take robust action and formal measures in response to widespread Spice use View source Lack of staff training and operational understanding of the CSRA policy View source Lack of assessment of Spice-related risks in cell-sharing decisions View source Lack of structured staff training on treatment of active racism alerts during cell-sharing assessments View source Failure to monitor CSRA policy implementation View source Failure to take robust action and formal measures in response to widespread prisoner-on-prisoner violence View source Failure to consider risks beyond the minimum CSRA when allocating prisoners to share a cell View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Sundeep Ghuman · 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
Sundeep Ghuman was a prisoner at HMP Belmarsh who was placed in a triple cell with a prisoner known to have racist and violent behaviour. On 18 February 2020, that prisoner violently assaulted Mr Ghuman with a table leg, and Mr Ghuman died in hospital on 19 February 2020 from a head injury. The principal concerns included failures in the CSRA process and training, inadequate treatment of racism alerts and other risk information, insufficient consideration of risks when allocating cellmates, and wider concerns about violence and drug use at HMP Belmarsh.
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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to take robust action and formal measures in response to widespread Spice use
Wider context from the report “The evidence overall was that HMP Belmarsh has widespread levels of violence by prisoners against other prisoners, and seemingly ubiquitous levels of Spice use in the prison . This seems to be at a level where staff do not consider that they can always take robust action and formal measures when this occurs . In those circumstances, I have a concern that the Prison may not currently be capable of providing a safe and secure environment for prisoners accommodated there, and that there is a risk of future deaths from drug use or violence .
” 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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Lack of staff training and operational understanding of the CSRA policy
Wider context from the report “In addition, the lack of understanding of the policy by all staff (including senior management) at HMP Belmarsh appears to reflect a systemic failing of training and operational understanding , and a disconnect between those responsible for creating and maintaining the policy and those taking operational decisions within prisons. The fact that the comprehensive misunderstanding of the policy by HMP Belmarsh over a period of many years was entirely unknown to those responsible for the policy, even in circumstances where HMP Belmarsh operated its own system (complete with bespoke “S1” stickers) and not picked up by any audit or monitoring procedure also indicates a failure in policy implementation.
” 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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Lack of assessment of Spice-related risks in cell-sharing decisions
Wider context from the report “There appears to be no consideration in HMPPS of the risks to prisoners from inhalation of Spice when a cellmate is a user or supplier , or of the risks of more easily exploited prisoners being led into Spice use by cellmates who use the drug, and no assessment of whether it is safe to place a prisoner in a cell with a user or supplier of Spice .
I am aware that deaths have been directly linked to Spice use. In the absence of any assessment of the risks in individual cases, there appears to be a risk of death of a prisoner through being placed into a cell with a known user or supplier of Spice .
” 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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Lack of structured staff training on treatment of active racism alerts during cell-sharing assessments
Wider context from the report “The lack of understanding of how an active alert for racism should be approached when assessing suitability sharing creates a risk of future fatal events. An unstructured approach and lack of training creates a risk that, as in this case, staff may inappropriately disregard an active alert for racism , leading to potentially fatal racist violence.
” 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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to monitor CSRA policy implementation
Wider context from the report “In addition, the lack of understanding of the policy by all staff (including senior management) at HMP Belmarsh appears to reflect a systemic failing of training and operational understanding, and a disconnect between those responsible for creating and maintaining the policy and those taking operational decisions within prisons. The fact that the comprehensive misunderstanding of the policy by HMP Belmarsh over a period of many years was entirely unknown to those responsible for the policy, even in circumstances where HMP Belmarsh operated its own system (complete with bespoke “S1” stickers) and not picked up by any audit or monitoring procedure also indicates a failure in policy implementation .
” 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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to take robust action and formal measures in response to widespread prisoner-on-prisoner violence
Wider context from the report “The evidence overall was that HMP Belmarsh has widespread levels of violence by prisoners against other prisoners , and seemingly ubiquitous levels of Spice use in the prison. This seems to be at a level where staff do not consider that they can always take robust action and formal measures when this occurs . In those circumstances, I have a concern that the Prison may not currently be capable of providing a safe and secure environment for prisoners accommodated there, and that there is a risk of future deaths from drug use or violence .
” 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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to consider risks beyond the minimum CSRA when allocating prisoners to share a cell
Wider context from the report “The evidence of staff at HMP Belmarsh (including from the Head of Security and Intelligence) was by contrast to the effect that moving into a cell are simply a daily occurrence and that as long as a CSRA says the individuals concerned can share then they can be moved in , and that no further consideration is necessary or appropriate . Consistently with this, the evidence of officers was that when arranging a cell move they would not look at the NOMIS notes of a prisoner, or other records, but solely at the CSRA to check that they were not High Risk (or “S1”).
” Open source report
10 Dec 2025 Mesut Olgun · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 1 Unavailability of Safer Cells outside the Segregation Unit for vulnerable prisoners View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Mesut Olgun · 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
Mesut Olgun sustained significant injuries while being arrested and was later seriously injured in his cell at HMP Hewell on 8 June 2018; he died from those injuries at Alexandra Hospital, Redditch, on 14 June 2018. The inquest concluded that he died as a result of suicide. Concerns included the lack of “Safer Cells” outside the Segregation Unit, failures to carry out most required ACCT observations, and failure to call a Code Blue emergency at the earliest opportunity; the inquest found that the latter two failures possibly 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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Unavailability of Safer Cells outside the Segregation Unit for vulnerable prisoners
Wider context from the report “In his evidence to the inquest, the current Head of Safety at HMP Hewell confirmed that the prison had two “Safer Cells” ( intended to reduce the risk ████████ ), but that these were both located within the prison’s Segregation Unit. He agreed that it would not be appropriate for a new prisoner like Mr. Olgun, who had been identified as a high risk of self-harm and for whom an ACCT document had been opened, to be located on the Segregation Unit on his first night in prison. There are therefore no “Safer Cells” located within the main body of the prison. The cost of converting a cell into a “Safer Cell” is said to be in the region of £70,000, for which funding would have to be sought from H.M. Prison and Probation Service, but HMP Hewell has not made any bid for such funding since Mr. Olgun’s death 7½ years ago.
The Head of Safety at the prison also confirmed in evidence that the two available “Safer Cells” have been used to house prisoners within the Segregation Unit who are thought to be at an increased risk of suicide or self-harm. This would suggest that the prison accepts in principle that such cells have a meaningful role to play in reducing such risk.
I am concerned that as long as “Safer Cells” are not made available away from the Segregation Unit at HMP Hewell, an important measure for reducing the risk of suicide or self-harm is being withheld from vulnerable prisoners at that prison.
” Open source report
8 Dec 2025 OLIVER MULANGALA · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 5 Use of drones to deliver drugs and other contraband into prison View source Easy availability of new psychoactive substances in prison View source Easy availability of mobile phones in prison View source Failure to hold statistics on drug-related deaths in prisons View source Failure to protect vulnerable prisoners from forced testing of illegal drugs 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
OLIVER MULANGALA · 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
Oliver Mulangala was in custody at HMP High Down, had epilepsy and a history of serious seizures, and was found dead in his cell on 13 July 2024 after suffering a drug-induced seizure. The report identifies concerns about the easy availability and use of illicit new psychoactive substances in HMP High Down, including their contribution to drug-related deaths, coercion and risks to prisoners. It also raises concerns about the availability of mobile phones and the use of drones to facilitate the delivery of drugs and other contraband into prisons.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Use of drones to deliver drugs and other contraband into prison
Wider context from the report “It is of grave concern that:
(1) New psychoactive substances, especially ███, are easily available in HM Prison High Down, as in many other prisons in England & Wales
a. New psychoactive substances are dangerous illegal drugs of abuse (there is no clinical or medical use for them) and they are responsible for the death of a prisoner in England and Wales about every 5 days
b. Prisoners are coming into prison without a drug habit and develop a drug habit in prison due to the ease of their availability
c. Vulnerable prisoners are being forced to test new batches of illegal drugs coming into the prison
(2) Mobile phones are easily available in HM Prison High Down, as in many other prisons in England & Wales
a. The access to mobile phones facilitates prisoners’ conduct and finance of drug dealing, including the arranging for the delivery of drugs by drones to precise locations at specified times
b. The access to mobile phones allows sharing information (including photographs and videos) across not only High Down prison, but across other prisons in England & Wales, presenting safety and security risks
c. The access to mobile phones facilitates the highly lucrative, damaging and dangerous activities of the organised criminal gangs working in HM High Down, and other prisons in England & Wales
(3) The use of ███ in HMP High Down, as in other prisons in England & Wales, presents a serious risk to prison safety and security
a. ███ facilitate the delivery of drugs into prison to precise locations at specified times
b. ███ can be used to bring in other contraband including weapons and even firearms
c. The increasing sophistication of ███ (and their increasing payload) increases the risks and dangers to life
(4) The Ministry of Justice advised the court that it does not hold statistics on drug-related deaths in prisons in England & Wales. Basic risk management requires risks to be quantified and assessed in order that they can be addressed. You cannot properly manage that which you do not measure.
” 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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Easy availability of new psychoactive substances in prison
Wider context from the report “It is of grave concern that:
(1) New psychoactive substances, especially ███, are easily available in HM Prison High Down, as in many other prisons in England & Wales
a. New psychoactive substances are dangerous illegal drugs of abuse (there is no clinical or medical use for them) and they are responsible for the death of a prisoner in England and Wales about every 5 days
b. Prisoners are coming into prison without a drug habit and develop a drug habit in prison due to the ease of their availability
c. Vulnerable prisoners are being forced to test new batches of illegal drugs coming into the prison
(2) Mobile phones are easily available in HM Prison High Down, as in many other prisons in England & Wales
a. The access to mobile phones facilitates prisoners’ conduct and finance of drug dealing, including the arranging for the delivery of drugs by drones to precise locations at specified times
b. The access to mobile phones allows sharing information (including photographs and videos) across not only High Down prison, but across other prisons in England & Wales, presenting safety and security risks
c. The access to mobile phones facilitates the highly lucrative, damaging and dangerous activities of the organised criminal gangs working in HM High Down, and other prisons in England & Wales
(3) The use of ███ in HMP High Down, as in other prisons in England & Wales, presents a serious risk to prison safety and security
a. ███ facilitate the delivery of drugs into prison to precise locations at specified times
b. ███ can be used to bring in other contraband including weapons and even firearms
c. The increasing sophistication of ███ (and their increasing payload) increases the risks and dangers to life
(4) The Ministry of Justice advised the court that it does not hold statistics on drug-related deaths in prisons in England & Wales. Basic risk management requires risks to be quantified and assessed in order that they can be addressed. You cannot properly manage that which you do not measure.
” 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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Easy availability of mobile phones in prison
Wider context from the report “It is of grave concern that:
(1) New psychoactive substances, especially ███, are easily available in HM Prison High Down, as in many other prisons in England & Wales
a. New psychoactive substances are dangerous illegal drugs of abuse (there is no clinical or medical use for them) and they are responsible for the death of a prisoner in England and Wales about every 5 days
b. Prisoners are coming into prison without a drug habit and develop a drug habit in prison due to the ease of their availability
c. Vulnerable prisoners are being forced to test new batches of illegal drugs coming into the prison
(2) Mobile phones are easily available in HM Prison High Down, as in many other prisons in England & Wales
a. The access to mobile phones facilitates prisoners’ conduct and finance of drug dealing, including the arranging for the delivery of drugs by drones to precise locations at specified times
b. The access to mobile phones allows sharing information (including photographs and videos) across not only High Down prison, but across other prisons in England & Wales, presenting safety and security risks
c. The access to mobile phones facilitates the highly lucrative, damaging and dangerous activities of the organised criminal gangs working in HM High Down, and other prisons in England & Wales
(3) The use of ███ in HMP High Down, as in other prisons in England & Wales, presents a serious risk to prison safety and security
a. ███ facilitate the delivery of drugs into prison to precise locations at specified times
b. ███ can be used to bring in other contraband including weapons and even firearms
c. The increasing sophistication of ███ (and their increasing payload) increases the risks and dangers to life
(4) The Ministry of Justice advised the court that it does not hold statistics on drug-related deaths in prisons in England & Wales. Basic risk management requires risks to be quantified and assessed in order that they can be addressed. You cannot properly manage that which you do not measure.
” 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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to hold statistics on drug-related deaths in prisons
Wider context from the report “It is of grave concern that:
(1) New psychoactive substances, especially ███, are easily available in HM Prison High Down, as in many other prisons in England & Wales
a. New psychoactive substances are dangerous illegal drugs of abuse (there is no clinical or medical use for them) and they are responsible for the death of a prisoner in England and Wales about every 5 days
b. Prisoners are coming into prison without a drug habit and develop a drug habit in prison due to the ease of their availability
c. Vulnerable prisoners are being forced to test new batches of illegal drugs coming into the prison
(2) Mobile phones are easily available in HM Prison High Down, as in many other prisons in England & Wales
a. The access to mobile phones facilitates prisoners’ conduct and finance of drug dealing, including the arranging for the delivery of drugs by drones to precise locations at specified times
b. The access to mobile phones allows sharing information (including photographs and videos) across not only High Down prison, but across other prisons in England & Wales, presenting safety and security risks
c. The access to mobile phones facilitates the highly lucrative, damaging and dangerous activities of the organised criminal gangs working in HM High Down, and other prisons in England & Wales
(3) The use of ███ in HMP High Down, as in other prisons in England & Wales, presents a serious risk to prison safety and security
a. ███ facilitate the delivery of drugs into prison to precise locations at specified times
b. ███ can be used to bring in other contraband including weapons and even firearms
c. The increasing sophistication of ███ (and their increasing payload) increases the risks and dangers to life
(4) The Ministry of Justice advised the court that it does not hold statistics on drug-related deaths in prisons in England & Wales . Basic risk management requires risks to be quantified and assessed in order that they can be addressed. You cannot properly manage that which you do not measure.
” 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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to protect vulnerable prisoners from forced testing of illegal drugs
Wider context from the report “It is of grave concern that:
(1) New psychoactive substances, especially ███, are easily available in HM Prison High Down, as in many other prisons in England & Wales
a. New psychoactive substances are dangerous illegal drugs of abuse (there is no clinical or medical use for them) and they are responsible for the death of a prisoner in England and Wales about every 5 days
b. Prisoners are coming into prison without a drug habit and develop a drug habit in prison due to the ease of their availability
c. Vulnerable prisoners are being forced to test new batches of illegal drugs coming into the prison
(2) Mobile phones are easily available in HM Prison High Down, as in many other prisons in England & Wales
a. The access to mobile phones facilitates prisoners’ conduct and finance of drug dealing, including the arranging for the delivery of drugs by drones to precise locations at specified times
b. The access to mobile phones allows sharing information (including photographs and videos) across not only High Down prison, but across other prisons in England & Wales, presenting safety and security risks
c. The access to mobile phones facilitates the highly lucrative, damaging and dangerous activities of the organised criminal gangs working in HM High Down, and other prisons in England & Wales
(3) The use of ███ in HMP High Down, as in other prisons in England & Wales, presents a serious risk to prison safety and security
a. ███ facilitate the delivery of drugs into prison to precise locations at specified times
b. ███ can be used to bring in other contraband including weapons and even firearms
c. The increasing sophistication of ███ (and their increasing payload) increases the risks and dangers to life
(4) The Ministry of Justice advised the court that it does not hold statistics on drug-related deaths in prisons in England & Wales. Basic risk management requires risks to be quantified and assessed in order that they can be addressed. You cannot properly manage that which you do not measure.
” Open source report
Concerns raised 1 Continuing availability and use of psychoactive substances posing significant health risks to prisoners View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Matthew Lucas Sundeep Singh · 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
Matthew Lucas Sundeep Singh, a prisoner at HMP Berwyn, was found unresponsive in his cell on 23 November 2019 after consuming a novel psychoactive substance and died shortly afterwards from cardiac arrest due to substance abuse. The report identified the continuing availability and use of psychoactive substances at HMP Berwyn, and the significant risks they pose to prisoners, as a concern for future deaths.
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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Continuing availability and use of psychoactive substances posing significant health risks to prisoners
Wider context from the report “It appears that there is continuing availability and use of psychoactive substances at HMP Berwyn despite ongoing initiatives.
I consider that the use of psychoactive substances and the significant risks which they pose to the health of prisoners at HMP Berwyn will be the cause of future deaths in the prison.
” Open source report
20 Oct 2025 Scott Stephen Berry · Prevention of Future Deaths report East Riding and Hull
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Concerns raised 2 Lack of access to Offender Delivery Programmes or therapeutic and progression units for unreleased IPP prisoners View source Delays in parole board review for unreleased IPP prisoners View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Scott Stephen Berry · 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
Scott Stephen Berry was a prisoner serving an Imprisonment for Public Protection sentence when, after expressing suicidal thoughts, he was found hanging on 12 October 2023. He was resuscitated and taken to hospital but died on 21 October 2023 after sustaining a hypoxic brain injury. The principal concern was that unreleased IPP prisoners may face prolonged detention, limited access to progression or therapeutic support, poor mental health and little hope of release, creating a risk of future deaths.
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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Lack of access to Offender Delivery Programmes or therapeutic and progression units for unreleased IPP prisoners
Wider context from the report “However, there still remains a large number of unreleased IPP prisoners in prison. For those who remain detained in prison, some many years after their original tariff, there is still a long period for them to wait for a review. These prisoners are, in many cases, still waiting for parole board review and not all have access to Offender Delivery Programmes or therapeutic and progression units to assist them .
These prisoners are suffering with their mental health and still have little hope of release. If action is not taken with regard to those still serving these sentences in prison, then there is a risk of future deaths occurring.
” 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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Delays in parole board review for unreleased IPP prisoners
Wider context from the report “However, there still remains a large number of unreleased IPP prisoners in prison. For those who remain detained in prison, some many years after their original tariff, there is still a long period for them to wait for a review . These prisoners are, in many cases, still waiting for parole board review and not all have access to Offender Delivery Programmes or therapeutic and progression units to assist them.
These prisoners are suffering with their mental health and still have little hope of release. If action is not taken with regard to those still serving these sentences in prison, then there is a risk of future deaths occurring.
” Open source report
19 Sep 2025 Rebekah Arter · Prevention of Future Deaths report South London
View report summary
Concerns raised 2 Failure to consider domestic abuse risk at police dismissal View source Failure of investigations to identify victims of domestic abuse and coercive control View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Rebekah Arter · 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
Rebekah Arter, aged 47, died in a hotel room in Barbados on 28 June 2024 in circumstances involving likely intoxication; the medical cause of death was unascertained and the inquest conclusion was open. The principal concern was that missed opportunities by the IOPC and Metropolitan Police Service may have prevented identification of Rebekah as a victim of domestic abuse and coercive control, and prevented protective action.
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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to consider domestic abuse risk at police dismissal
Wider context from the report “That there may have been missed opportunities for the IOPC and Metropolitan Police Service from their investigations to identify that Rebekah was a victim of domestic abuse and coercive control, which would have enabled her to be protected. This is illustrated by these facts:
• That Rebekah had met her husband initially as a victim of a crime.
• That police investigations uncovered a large number of women with whom he had inappropriate relationships and that he misused his police powers.
• That he was dismissed from the police for drug offences in May 2023, but the risk to Rebekah was not apparently considered at that time .
• A witness has alleged that a video was sent by him of Rebekah ████████ which the family allege was used to shame and enforce control over her, allegedly in 2023.
• A history of her having unexplained repeated bruises and injuries was available in 2024 to anyone who enquired about the risk of domestic abuse.
• ████████
• That in retrospect it is recognised by a Detective Chief Inspector that he was an exceptionally persistent and damaging offender against women, but no charges in relation to that had ever been brought.
The coroner did not accept submissions from the family that the inquest engaged Article 2 of the European Convention on Human Rights and ruled that details of the seven years of conduct investigations were beyond the scope of the inquest.
” 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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure of investigations to identify victims of domestic abuse and coercive control
Wider context from the report “That there may have been missed opportunities for the IOPC and Metropolitan Police Service from their investigations to identify that Rebekah was a victim of domestic abuse and coercive control , which would have enabled her to be protected. This is illustrated by these facts:
• That Rebekah had met her husband initially as a victim of a crime.
• That police investigations uncovered a large number of women with whom he had inappropriate relationships and that he misused his police powers.
• That he was dismissed from the police for drug offences in May 2023, but the risk to Rebekah was not apparently considered at that time.
• A witness has alleged that a video was sent by him of Rebekah ████████ which the family allege was used to shame and enforce control over her, allegedly in 2023.
• A history of her having unexplained repeated bruises and injuries was available in 2024 to anyone who enquired about the risk of domestic abuse .
• ████████
• That in retrospect it is recognised by a Detective Chief Inspector that he was an exceptionally persistent and damaging offender against women, but no charges in relation to that had ever been brought.
The coroner did not accept submissions from the family that the inquest engaged Article 2 of the European Convention on Human Rights and ruled that details of the seven years of conduct investigations were beyond the scope of the inquest.
” Open source report
17 Sep 2025 Martin COLLINS · Prevention of Future Deaths report Suffolk
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Concerns raised 2 Failure to notify prison staff or healthcare of high or unusual prisoner telephone-call volumes View source Failure to monitor prisoners' telephone-call volumes for high or unusual patterns View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Martin COLLINS · 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
Martin Collins, a 66-year-old male serving a prison sentence, died by suicide after being found suspended in his cell at HMP Highpoint on 25 November 2023. The report raises concerns that the prison telephone system could not automatically identify unusually high call volumes and alert staff or healthcare, potentially missing opportunities to identify risk triggers and intervene.
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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to notify prison staff or healthcare of high or unusual prisoner telephone-call volumes
Wider context from the report “The available telephone system for prisoners does not presently have the capability, in an automated manner, to recognise high or unusual volumes of calls by prisoners - and then to notify prison staff or healthcare in the event of such a pattern . This is despite the fact that the data on telephone calls made by a particular prisoner is available and is readily capable of being obtained, such that patterns of calls could be monitored manually by staff.
The lack of system for monitoring of volumes of prisoners' telephone calls may lead to missed opportunities to identify risk triggers and so missed opportunities to intervene and prevent 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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to monitor prisoners' telephone-call volumes for high or unusual patterns
Wider context from the report “The available telephone system for prisoners does not presently have the capability, in an automated manner, to recognise high or unusual volumes of calls by prisoners - and then to notify prison staff or healthcare in the event of such a pattern. This is despite the fact that the data on telephone calls made by a particular prisoner is available and is readily capable of being obtained, such that patterns of calls could be monitored manually by staff.
The lack of system for monitoring of volumes of prisoners' telephone calls may lead to missed opportunities to identify risk triggers and so missed opportunities to intervene and prevent suicide.
” Open source report
29 Jul 2025 Azroy Dawes-Clarke · Prevention of Future Deaths report Kent and Medway
View report summary
Concerns raised 2 Failure to establish clear command and control arrangements during critical medical emergencies in custodial settings View source Failure to establish a communication strategy during critical medical emergencies in custodial settings View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Azroy Dawes-Clarke · 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
Azroy Dawes-Clarke died in hospital after self-ligaturing in HMP Elmley, followed by restraint, cardiac and respiratory arrest, and further arrests during conveyance and hospital treatment. The principal concerns included confused communication and unclear command structures among prison staff, healthcare professionals and paramedics, disproportionate and prolonged restraint, delays in obtaining medical assistance and starting CPR, and inadequate consideration of his breathing and positioning.
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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to establish clear command and control arrangements during critical medical emergencies in custodial settings
Wider context from the report “(1) As the jury noted, communication between attending prison staff, healthcare professionals and paramedics was confused. There was confusion as to who had command and control of the medical emergency, which public body took primacy and the difference in roles and responsibilities . Those attending the scene did not establish any sort of communication strategy or command structure . During prevention of future deaths evidence, there remained a lack of clarity and consistency as to how such a situation would be avoided if a critical medical emergency eventuated in a custodial setting again .
(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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to establish a communication strategy during critical medical emergencies in custodial settings
Wider context from the report “(1) As the jury noted, communication between attending prison staff, healthcare professionals and paramedics was confused . There was confusion as to who had command and control of the medical emergency, which public body took primacy and the difference in roles and responsibilities. Those attending the scene did not establish any sort of communication strategy or command structure. During prevention of future deaths evidence, there remained a lack of clarity and consistency as to how such a situation would be avoided if a critical medical emergency eventuated in a custodial setting again .
(2)
(3)
” Open source report
25 Jul 2025 Sheldon Lawrence Jeans · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 4 Lack of policy and guidance informing prison staff of the dangers of illicitly brewed alcohol View source Failure to secure in-possession medication against access by other prisoners View source Lack of policy and guidance governing access to and use of illicitly brewed alcohol in prisons View source Failure to ensure return of excess medication after prescription discontinuation View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Sheldon Lawrence Jeans · 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
On 13 November 2022, Sheldon Lawrence Jeans, a serving prisoner at HMP Guys Marsh, was found collapsed and unresponsive in his cell. The inquest recorded that he died following an idiosyncratic response to alcoholic intoxication and medicinal drugs, combined with partial postural asphyxia. The report raised concerns about the lack of guidance on illicitly brewed alcohol and the governance, storage and return of medication held by prisoners.
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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Lack of policy and guidance informing prison staff of the dangers of illicitly brewed alcohol
Wider context from the report “(1) There is a lack of national policy, and local guidance at HMP Guys Marsh, to inform staff working in prisons of the dangers of illicitly brewed alcohol, also known as hooch. There is also a lack of policy and guidance to assist those working within the prisoner estate with the management and governance of the access to, and use of, illicitly brewed alcohol.
Illicitly brewed alcohol is a common substance across the prisoner estate. Evidence was given at the Inquest that in the month of September 2022, 215.5 litres of illicitly brewed alcohol were seized at HMP Guys Marsh. Evidence was given that Hooch continues to be a common problem in prisons. Illicitly brewed alcohol in prison is a substance made from items which are readily and legitimately available to prisoners.
Hooch was described as a very, very dangerous substance during the course of the evidence and as is clear from the cause of his death, was central to the death of Sheldon. Evidence was given that it has sedative effects which if taken with certain medications can increase the sedative effects.
Evidence was given that the policies in place concerning the possession and use of illicit substances within the prisoner estate at the time of Sheldon’s death, and those in place now, focus on drugs or medication, but are silent in relation to alcohol. I am concerned that this lack of guidance could lead to a future death in prison custody
” 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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to secure in-possession medication against access by other prisoners
Wider context from the report “(2) Prisoners can have access to certain medication to hold in their possession which could be accessed by other prisoners and there is a lack of national policy, and local policy at HMP Guys Marsh, from a healthcare and prison perspective, around the governance of medication held in possession in the prisoner estate.
Evidence was heard that when a person is prescribed medication in prison, it can either be taken under supervision, or a prisoner can be provided with the medication to hold in their possession, in their cell.
In these cases, the prisoner is responsible for the safety of that medication. Prior to being provided with medication in their possession a risk assessment is undertaken upon the prisoner to assess the risks associated with the drug and also the risks associated with prisoner. Whilst medications defined as controlled drugs would not be given in possession, it is possible to have medication that could cause death in possession. Although Sheldon was not prescribed the medications that caused his death, evidence was given some of those medications are suitable to be prescribed to a prisoner in possession. It is not know how Sheldon accessed the medication found in his system at the time of his death, other than to say he obtained it at HMP Guys Marsh.
At HMP Guys Marsh, which may not be the case across the prisoner estate, a lockable cupboard is provided in cells for the storage of medication.
Evidence was given that at times cells will be left insecure at HMP Guys Marsh when the prison is in a state of unlock, such as when prisoners collect meals or for example when they go for showers or are out of the cells on association. Evidence was given that prisoners go into each other's cells when they are in a state of unlock. Prisoners could therefore enter another prisoner's cell. If medication is not held securely in a lockable cupboard there is a risk that prisoners who are not prescribed medication, could access medication.
Evidence was given at the Inquest that due to the chaotic life some prisoners lead, even when provided with lockable cupboards, cells at HMP Guys Marsh have been seen to contain medication that is not secure and is strewn all over the cell. The medication in Sheldon’s cell at the time of his death was found insecure in a Tupperware container.
Further, if a medication prescribed to a prisoner is discontinued, evidence was heard that the onus is upon the prisoner returning any excess medication to the healthcare department at HMP Guys Marsh which may be the position in other prisons.
The issues around securing of medication held in possession in a cell and the onus being upon prisoners to return unused medication, carries a risk of prisoners accessing unprescribed medication. At the time of Sheldon’s death he was not prescribed the medications found in his system and he had in his cell excessive amounts of medication he was prescribed and had previously been prescribed and discontinued.
I am therefore concerned the lack of guidance and policy nationally, and locally at HMP Guys Marsh, on storage of in possession medication and what to do when a medication is discontinued to ensure prisoners do not continue to possess left over medication, could lead to future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Lack of policy and guidance governing access to and use of illicitly brewed alcohol in prisons
Wider context from the report “(1) There is a lack of national policy, and local guidance at HMP Guys Marsh, to inform staff working in prisons of the dangers of illicitly brewed alcohol, also known as hooch. There is also a lack of policy and guidance to assist those working within the prisoner estate with the management and governance of the access to, and use of, illicitly brewed alcohol.
Illicitly brewed alcohol is a common substance across the prisoner estate. Evidence was given at the Inquest that in the month of September 2022, 215.5 litres of illicitly brewed alcohol were seized at HMP Guys Marsh. Evidence was given that Hooch continues to be a common problem in prisons. Illicitly brewed alcohol in prison is a substance made from items which are readily and legitimately available to prisoners.
Hooch was described as a very, very dangerous substance during the course of the evidence and as is clear from the cause of his death, was central to the death of Sheldon. Evidence was given that it has sedative effects which if taken with certain medications can increase the sedative effects.
Evidence was given that the policies in place concerning the possession and use of illicit substances within the prisoner estate at the time of Sheldon’s death, and those in place now, focus on drugs or medication, but are silent in relation to alcohol. I am concerned that this lack of guidance could lead to a future death in prison custody
” 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 Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure return of excess medication after prescription discontinuation
Wider context from the report “(2) Prisoners can have access to certain medication to hold in their possession which could be accessed by other prisoners and there is a lack of national policy, and local policy at HMP Guys Marsh, from a healthcare and prison perspective, around the governance of medication held in possession in the prisoner estate.
Evidence was heard that when a person is prescribed medication in prison, it can either be taken under supervision, or a prisoner can be provided with the medication to hold in their possession, in their cell.
In these cases, the prisoner is responsible for the safety of that medication. Prior to being provided with medication in their possession a risk assessment is undertaken upon the prisoner to assess the risks associated with the drug and also the risks associated with prisoner. Whilst medications defined as controlled drugs would not be given in possession, it is possible to have medication that could cause death in possession. Although Sheldon was not prescribed the medications that caused his death, evidence was given some of those medications are suitable to be prescribed to a prisoner in possession. It is not know how Sheldon accessed the medication found in his system at the time of his death, other than to say he obtained it at HMP Guys Marsh.
At HMP Guys Marsh, which may not be the case across the prisoner estate, a lockable cupboard is provided in cells for the storage of medication.
Evidence was given that at times cells will be left insecure at HMP Guys Marsh when the prison is in a state of unlock, such as when prisoners collect meals or for example when they go for showers or are out of the cells on association. Evidence was given that prisoners go into each other's cells when they are in a state of unlock. Prisoners could therefore enter another prisoner's cell. If medication is not held securely in a lockable cupboard there is a risk that prisoners who are not prescribed medication, could access medication.
Evidence was given at the Inquest that due to the chaotic life some prisoners lead, even when provided with lockable cupboards, cells at HMP Guys Marsh have been seen to contain medication that is not secure and is strewn all over the cell. The medication in Sheldon’s cell at the time of his death was found insecure in a Tupperware container.
Further, if a medication prescribed to a prisoner is discontinued, evidence was heard that the onus is upon the prisoner returning any excess medication to the healthcare department at HMP Guys Marsh which may be the position in other prisons.
The issues around securing of medication held in possession in a cell and the onus being upon prisoners to return unused medication, carries a risk of prisoners accessing unprescribed medication. At the time of Sheldon’s death he was not prescribed the medications found in his system and he had in his cell excessive amounts of medication he was prescribed and had previously been prescribed and discontinued.
I am therefore concerned the lack of guidance and policy nationally, and locally at HMP Guys Marsh, on storage of in possession medication and what to do when a medication is discontinued to ensure prisoners do not continue to possess left over medication , could lead to future deaths.
” 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