18 Jul 2025 Patryk Gladysz · Prevention of Future Deaths report Inner West London
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Concerns raised 8 Out-of-date First Aid refresher training for healthcare staff View source Failure of prison and healthcare staff to share knowledge about people presenting with serious and enduring mental health illness View source Inconsistent understanding among prison and healthcare staff of healthcare access to NOMIS View source Ongoing challenges in prison officer checks of roll calls and ACCT observations View source Insufficient Mental Health in-reach team staffing for timely meaningful and quality mental health assessments View source Deactivation of healthcare staff NOMIS accounts due to lack of use View source Lack of prison staff knowledge of the heightened risk of foreign nationals in custody View source Staffing levels diluting key worker scheme requirements View source See 5 more concerns
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Patryk Gladysz · 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
Patryk Gladysz, who had schizophrenia and was detained at HMP Wandsworth, was found in his cell with a ligature around his neck on 5 January 2024 and died at St George’s Hospital. The inquest concluded that he had hung himself with a ligature, with his intentions unknown. Concerns included delays and staffing pressures affecting mental health assessments, inadequate communication between prison and healthcare staff, gaps in knowledge of his history and risks, and shortcomings in prison monitoring and 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PFD Monitor interpretation Out-of-date First Aid refresher training for healthcare staff
Wider context from the report “(6) First Aid refresher training is not up to date for all healthcare staff .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure of prison and healthcare staff to share knowledge about people presenting with serious and enduring mental health illness
Wider context from the report “(4) Communication between prison and healthcare staff regarding: (a) knowledge sharing of those presenting with a serious and enduring mental health illness, such as schizophrenia ; (b) inconsistent understanding of healthcare access to the NOMIS by both prison and healthcare staff; and (c) de-activation of NOMIS accounts for healthcare staff due to lack of use – 21 healthcare accounts were de-activated notwithstanding an increase in available terminals.
” 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 understanding among prison and healthcare staff of healthcare access to NOMIS
Wider context from the report “(4) Communication between prison and healthcare staff regarding: (a) knowledge sharing of those presenting with a serious and enduring mental health illness, such as schizophrenia; (b) inconsistent understanding of healthcare access to the NOMIS by both prison and healthcare staff ; and (c) de-activation of NOMIS accounts for healthcare staff due to lack of use – 21 healthcare accounts were de-activated notwithstanding an increase in available terminals.
” 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 Ongoing challenges in prison officer checks of roll calls and ACCT observations
Wider context from the report “(5) Prison officer checks of roll calls/ACCT observations - recent audit by HMP Wandsworth suggests on-going challenges .
” 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 Mental Health in-reach team staffing for timely meaningful and quality mental health assessments
Wider context from the report “(1) Staffing within the Mental Health in-reach team impacting the timely undertaking of meaningful and quality mental health assessments .
” 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 Deactivation of healthcare staff NOMIS accounts due to lack of use
Wider context from the report “(4) Communication between prison and healthcare staff regarding: (a) knowledge sharing of those presenting with a serious and enduring mental health illness, such as schizophrenia; (b) inconsistent understanding of healthcare access to the NOMIS by both prison and healthcare staff; and (c) de-activation of NOMIS accounts for healthcare staff due to lack of use – 21 healthcare accounts were de-activated notwithstanding an increase in available terminals .
” 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 prison staff knowledge of the heightened risk of foreign nationals in custody
Wider context from the report “(3) Knowledge of prison staff of the heightened risk of foreign nationals in custody , despite a higher proportion of foreign nationals being detained at HMP Wandsworth.
” 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 Staffing levels diluting key worker scheme requirements
Wider context from the report “(2) Staffing within HMP Wandsworth resulting in a dilution to the requirements for the key worker scheme .
” Open source report
4 Jul 2025 George EMMETT · Prevention of Future Deaths report Buckinghamshire
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Concerns raised 1 Failure of operational staff to follow local medical emergency response protocols View source
Responses linked to these concerns
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No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
George EMMETT · 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 Emmett died after taking synthetic cannabinoid in G-Wing at HMP Aylesbury on 25 May 2023. The report raises a continuing concern that emergency responses involving prisoners may be compromised if staff do not follow the HMPPS Medical Emergency Response Codes policy, including promptly summoning an ambulance and calling a Code Blue.
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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 of operational staff to follow local medical emergency response protocols
Wider context from the report “Evidence at the inquest demonstrated a Code Blue should be called over the radio from the cell location where a situation such as that in which George was found has arisen.
The evidence of OSG ████████ did not appear to demonstrate familiarity with the processes set out in this policy at the time of George's death, nor any greater familiarity during evidence given, some two years after George's death.
It is understood OSG ████████ holds a similar role at HMP Woodhill.
There is a continuing concern that optimum reaction to an emergency situation involving the health of a prisoner may be compromised if OSG ████████ were to react in a manner which was not in accordance with any local protocols reflective of the HMPPS Medical Emergency Response Codes policy.
The circumstances anticipated by this policy include situations where a prisoner's death may be prevented with appropriate application of an emergency response.
” Open source report
28 May 2025 Samuel Anthony Donald STEWART · Prevention of Future Deaths report West London
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Concerns raised 2 Failure to support and discuss positive drug test results with prisoners View source Failure to ensure clear and followed pathways for action after a positive drug test 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
Samuel Anthony Donald STEWART · 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
Samuel Stewart was found deceased in his cell at HMP Wormwood Scrubs on 15 July 2023, with drugs paraphernalia in the cell. His death was due to drugs in combination with long-term cardiac damage. A positive drug test on 6 March 2023 was not followed by discussion, support, or a multidisciplinary meeting, and the pathways after a positive result were unclear or not followed.
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 support and discuss positive drug test results with prisoners
Wider context from the report “Sam had elected to have a place on a "drug free" wing and accepted the conditions of this placement. He accessed non-prescribed drugs (amphetamines) as his test on 6 March 2023 yielded a positive result. No action was taken by either the prison or healthcare.
(1) consideration should be given as to what actions should have been taken, and if this is set out in the national or local policy guidelines
(2) pathways after a positive test result were either not followed or unclear
(3) An opportunity was missed to support Sam and discuss this with him
” 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 clear and followed pathways for action after a positive drug test
Wider context from the report “Sam had elected to have a place on a "drug free" wing and accepted the conditions of this placement. He accessed non-prescribed drugs (amphetamines) as his test on 6 March 2023 yielded a positive result. No action was taken by either the prison or healthcare.
(1) consideration should be given as to what actions should have been taken, and if this is set out in the national or local policy guidelines
(2) pathways after a positive test result were either not followed or unclear
(3) An opportunity was missed to support Sam and discuss this with him
” Open source report
2 May 2025 Sarah Frances BOYLE · Prevention of Future Deaths report Cheshire
View report summary
Concerns raised 8 Failure to respond reliably to expressions of self harm or suicidality View source ACCT observations failing to provide therapeutic support View source Insufficient mental health input for women not case loaded to the mental health team View source Delays in transferring women requiring mental health inpatient treatment View source Insufficient staffing capacity to complete ACCT checks and documentation View source Inconsistent completion of the ACCT process View source Insufficient mental health team capacity for women awaiting assessment or inpatient beds View source Insufficient mental health training and time for prison officers conducting meaningful ACCT conversations View source See 5 more concerns
Responses linked to these concerns
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Sarah Frances BOYLE · 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
Sarah Boyle was detained at HMP Styal and was monitored under the ACCT process after expressing thoughts of self-harm or suicide and making several ligature attempts. On 14 July 2024, she was found with a ligature around her neck, suffered irreversible brain damage, and died in hospital on 20 July 2024. The report raises concerns that the ACCT process at HMP Styal was not working effectively, citing high levels of self-harm, complex mental-health needs, understaffing, missed checks, and inconsistent completion of the process.
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 respond reliably to expressions of self harm or suicidality
Wider context from the report “I am concerned that the ACCT process or system currently in place designed to keep women safe at HMP Styal is not working effectively, and that there is a risk of future deaths if the process is not reconsidered or amended to better suit the needs of this prison. The ACCT process allows for observations of a woman who is at risk of self harm or suicide to keep her safe, but these are not a therapeutic observation and are essentially a check to ensure that the woman is alive and not actively self harming. Mental health input, if a woman is not case loaded to the mental health team, can be minimal, limited to attendance at a case review at best, and this does not allow for an opportunity to improve the woman’s mental health, to reduce the risk of future suicide attempts. Care plans allowing for meaningful activity assist but their effectiveness is limited alongside the prison regime. I acknowledge that prison is not intended to be a therapeutic environment but given the number of women with mental health needs, I am concerned that the current environment or processes will give rise to a risk of future deaths.
My concerns are based on the following points which I heard in evidence:
• HMP Styal is a women’s prison with a high number of self inflicted deaths, compared to the rest of the female estate. I am told by the prison ombudsman that they have the highest number of deaths between January 2022 and January 2025, accounting on my calculation for almost half of the total deaths in the female estate across England. I am aware that there has been one self inflicted death this year to date, and we are only 4 months in;
• I heard evidence from the Head of Safer Prisons and Equality at HMP Styal and the Service Manager for Greater Manchester Mental Health NHS FT, who provide the mental health care in the prison, that the mental health needs of the women detained at Styal are high and can be complex. The latter explained that they receive women from court who have been sent to prison following a criminal act but are essentially awaiting assessment to see whether they should be detained in prison, or in a mental health hospital. The mental health team is then expected to care for the woman for the prolonged period of assessment and awaiting a bed if deemed necessary, something they are not set up to do. It was the view of this witness that Styal was receiving a number of prisoners who are complex and risky and require treatment in a mental health hospital. The process for transfer then takes time and is an additional pressure on the team. The powers of a mental health team in prison are far more restricted, for example, they cannot force medication if needed, and it is reliant on the engagement of prisoners which they frequently do not get. The mental health Trust confirmed that in 2025 to date (29.4.25), 11 prisoners have been referred for a Mental Health Act assessment and of these 11, 8 were accepted for transfer and treatment in a mental health inpatient setting;
• It was the evidence of the Head of Safer Prisons and Equality that they also receive women who are there for a ‘warrant of concern’. A ‘warrant of concern’ is where a woman attends court and is not sentenced at that point but remanded into prison custody due to the Judge having concerns that they are not safe to be released into the community and where it is perceived that they will be safer in custody. This is usually where there are concerns around the woman’s mental health and/or risk to self. This adds pressure on an already stretched resource level in prisons as more resources are generally required to manage such complex individuals; Prison data suggests that HMP Styal have received 7 women on ‘warrants of concern’ since November 2024 to date (April 2025);
• I heard from one witness that a ‘good day’ on one side of the wing would just be one incident of self harm, but there would be frequently multiple incidents;
• The number of number of self harm incidents and ACCT documents open appears to have hardened the prison team to expressions of self harm etc. I heard comments throughout the inquest such as “If I opened an ACCT on every woman who said she was suicidal we’d have loads open”, and “2 incidents of self harm in a morning for one prisoner might seem like a lot but it’s not in the context of Styal”. This may lead to key cases being missed ;
• The number of ACCTs open within the prison can be high given the mental health need. I have heard evidence from a number of witnesses as to the pressures that the ACCT process places on staff, primarily due to the high number compared to staffing numbers. The severity of this varied in evidence depending seemingly on whether the member of staff was still with the prison service or had left. The clear consensus however was that the carrying out of ACCT checks, meaningful conversations and documentation of this was difficult whilst also trying to manage the day to day regime. It was accepted by the Head of Safer Prisons and Equality at HMP Styal that the officer on duty on the day of Sarah’s death would have been responsible for 48 checks an hour, and that was not unusual. Evidence from one witness, who has since left the prison, was that as a result of the number of checks required, and the limited resource to do them, checks were frequently missed;
• Meaningful conversations, designed to find out how the person is feeling and check in with them, are being carried out by prison officers with very limited mental health training, with very limited time resource to do this. Mental health training is not mandatory for the officers and can be overlooked due to more pressing, mandatory training.
The jury findings record “Understaffing and a high number of ACCT documents at HMP Styal led to inconsistencies with how staff completed each part of the ACCT process”.
In addition to the evidence heard from the witnesses, I am mindful of the report of HM Chief Inspector of Prisons (Time to care: what helps women cope in prison February 2025) which notes that the rate of self harm among women in prison is now 8.5 times higher than in men’s jails, and highlights a number of issues which continue to this, which have been reflected in this 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 ACCT observations failing to provide therapeutic support
Wider context from the report “I am concerned that the ACCT process or system currently in place designed to keep women safe at HMP Styal is not working effectively, and that there is a risk of future deaths if the process is not reconsidered or amended to better suit the needs of this prison. The ACCT process allows for observations of a woman who is at risk of self harm or suicide to keep her safe, but these are not a therapeutic observation and are essentially a check to ensure that the woman is alive and not actively self harming . Mental health input, if a woman is not case loaded to the mental health team, can be minimal, limited to attendance at a case review at best, and this does not allow for an opportunity to improve the woman’s mental health, to reduce the risk of future suicide attempts. Care plans allowing for meaningful activity assist but their effectiveness is limited alongside the prison regime. I acknowledge that prison is not intended to be a therapeutic environment but given the number of women with mental health needs, I am concerned that the current environment or processes will give rise to a risk of future deaths.
My concerns are based on the following points which I heard in evidence:
• HMP Styal is a women’s prison with a high number of self inflicted deaths, compared to the rest of the female estate. I am told by the prison ombudsman that they have the highest number of deaths between January 2022 and January 2025, accounting on my calculation for almost half of the total deaths in the female estate across England. I am aware that there has been one self inflicted death this year to date, and we are only 4 months in;
• I heard evidence from the Head of Safer Prisons and Equality at HMP Styal and the Service Manager for Greater Manchester Mental Health NHS FT, who provide the mental health care in the prison, that the mental health needs of the women detained at Styal are high and can be complex. The latter explained that they receive women from court who have been sent to prison following a criminal act but are essentially awaiting assessment to see whether they should be detained in prison, or in a mental health hospital. The mental health team is then expected to care for the woman for the prolonged period of assessment and awaiting a bed if deemed necessary, something they are not set up to do. It was the view of this witness that Styal was receiving a number of prisoners who are complex and risky and require treatment in a mental health hospital. The process for transfer then takes time and is an additional pressure on the team. The powers of a mental health team in prison are far more restricted, for example, they cannot force medication if needed, and it is reliant on the engagement of prisoners which they frequently do not get. The mental health Trust confirmed that in 2025 to date (29.4.25), 11 prisoners have been referred for a Mental Health Act assessment and of these 11, 8 were accepted for transfer and treatment in a mental health inpatient setting;
• It was the evidence of the Head of Safer Prisons and Equality that they also receive women who are there for a ‘warrant of concern’. A ‘warrant of concern’ is where a woman attends court and is not sentenced at that point but remanded into prison custody due to the Judge having concerns that they are not safe to be released into the community and where it is perceived that they will be safer in custody. This is usually where there are concerns around the woman’s mental health and/or risk to self. This adds pressure on an already stretched resource level in prisons as more resources are generally required to manage such complex individuals; Prison data suggests that HMP Styal have received 7 women on ‘warrants of concern’ since November 2024 to date (April 2025);
• I heard from one witness that a ‘good day’ on one side of the wing would just be one incident of self harm, but there would be frequently multiple incidents;
• The number of number of self harm incidents and ACCT documents open appears to have hardened the prison team to expressions of self harm etc. I heard comments throughout the inquest such as “If I opened an ACCT on every woman who said she was suicidal we’d have loads open”, and “2 incidents of self harm in a morning for one prisoner might seem like a lot but it’s not in the context of Styal”. This may lead to key cases being missed;
• The number of ACCTs open within the prison can be high given the mental health need. I have heard evidence from a number of witnesses as to the pressures that the ACCT process places on staff, primarily due to the high number compared to staffing numbers. The severity of this varied in evidence depending seemingly on whether the member of staff was still with the prison service or had left. The clear consensus however was that the carrying out of ACCT checks, meaningful conversations and documentation of this was difficult whilst also trying to manage the day to day regime. It was accepted by the Head of Safer Prisons and Equality at HMP Styal that the officer on duty on the day of Sarah’s death would have been responsible for 48 checks an hour, and that was not unusual. Evidence from one witness, who has since left the prison, was that as a result of the number of checks required, and the limited resource to do them, checks were frequently missed;
• Meaningful conversations, designed to find out how the person is feeling and check in with them, are being carried out by prison officers with very limited mental health training, with very limited time resource to do this. Mental health training is not mandatory for the officers and can be overlooked due to more pressing, mandatory training.
The jury findings record “Understaffing and a high number of ACCT documents at HMP Styal led to inconsistencies with how staff completed each part of the ACCT process”.
In addition to the evidence heard from the witnesses, I am mindful of the report of HM Chief Inspector of Prisons (Time to care: what helps women cope in prison February 2025) which notes that the rate of self harm among women in prison is now 8.5 times higher than in men’s jails, and highlights a number of issues which continue to this, which have been reflected in this 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 Insufficient mental health input for women not case loaded to the mental health team
Wider context from the report “I am concerned that the ACCT process or system currently in place designed to keep women safe at HMP Styal is not working effectively, and that there is a risk of future deaths if the process is not reconsidered or amended to better suit the needs of this prison. The ACCT process allows for observations of a woman who is at risk of self harm or suicide to keep her safe, but these are not a therapeutic observation and are essentially a check to ensure that the woman is alive and not actively self harming. Mental health input, if a woman is not case loaded to the mental health team, can be minimal, limited to attendance at a case review at best , and this does not allow for an opportunity to improve the woman’s mental health, to reduce the risk of future suicide attempts. Care plans allowing for meaningful activity assist but their effectiveness is limited alongside the prison regime. I acknowledge that prison is not intended to be a therapeutic environment but given the number of women with mental health needs, I am concerned that the current environment or processes will give rise to a risk of future deaths.
My concerns are based on the following points which I heard in evidence:
• HMP Styal is a women’s prison with a high number of self inflicted deaths, compared to the rest of the female estate. I am told by the prison ombudsman that they have the highest number of deaths between January 2022 and January 2025, accounting on my calculation for almost half of the total deaths in the female estate across England. I am aware that there has been one self inflicted death this year to date, and we are only 4 months in;
• I heard evidence from the Head of Safer Prisons and Equality at HMP Styal and the Service Manager for Greater Manchester Mental Health NHS FT, who provide the mental health care in the prison, that the mental health needs of the women detained at Styal are high and can be complex. The latter explained that they receive women from court who have been sent to prison following a criminal act but are essentially awaiting assessment to see whether they should be detained in prison, or in a mental health hospital. The mental health team is then expected to care for the woman for the prolonged period of assessment and awaiting a bed if deemed necessary, something they are not set up to do. It was the view of this witness that Styal was receiving a number of prisoners who are complex and risky and require treatment in a mental health hospital. The process for transfer then takes time and is an additional pressure on the team. The powers of a mental health team in prison are far more restricted, for example, they cannot force medication if needed, and it is reliant on the engagement of prisoners which they frequently do not get. The mental health Trust confirmed that in 2025 to date (29.4.25), 11 prisoners have been referred for a Mental Health Act assessment and of these 11, 8 were accepted for transfer and treatment in a mental health inpatient setting;
• It was the evidence of the Head of Safer Prisons and Equality that they also receive women who are there for a ‘warrant of concern’. A ‘warrant of concern’ is where a woman attends court and is not sentenced at that point but remanded into prison custody due to the Judge having concerns that they are not safe to be released into the community and where it is perceived that they will be safer in custody. This is usually where there are concerns around the woman’s mental health and/or risk to self. This adds pressure on an already stretched resource level in prisons as more resources are generally required to manage such complex individuals; Prison data suggests that HMP Styal have received 7 women on ‘warrants of concern’ since November 2024 to date (April 2025);
• I heard from one witness that a ‘good day’ on one side of the wing would just be one incident of self harm, but there would be frequently multiple incidents;
• The number of number of self harm incidents and ACCT documents open appears to have hardened the prison team to expressions of self harm etc. I heard comments throughout the inquest such as “If I opened an ACCT on every woman who said she was suicidal we’d have loads open”, and “2 incidents of self harm in a morning for one prisoner might seem like a lot but it’s not in the context of Styal”. This may lead to key cases being missed;
• The number of ACCTs open within the prison can be high given the mental health need. I have heard evidence from a number of witnesses as to the pressures that the ACCT process places on staff, primarily due to the high number compared to staffing numbers. The severity of this varied in evidence depending seemingly on whether the member of staff was still with the prison service or had left. The clear consensus however was that the carrying out of ACCT checks, meaningful conversations and documentation of this was difficult whilst also trying to manage the day to day regime. It was accepted by the Head of Safer Prisons and Equality at HMP Styal that the officer on duty on the day of Sarah’s death would have been responsible for 48 checks an hour, and that was not unusual. Evidence from one witness, who has since left the prison, was that as a result of the number of checks required, and the limited resource to do them, checks were frequently missed;
• Meaningful conversations, designed to find out how the person is feeling and check in with them, are being carried out by prison officers with very limited mental health training, with very limited time resource to do this. Mental health training is not mandatory for the officers and can be overlooked due to more pressing, mandatory training.
The jury findings record “Understaffing and a high number of ACCT documents at HMP Styal led to inconsistencies with how staff completed each part of the ACCT process”.
In addition to the evidence heard from the witnesses, I am mindful of the report of HM Chief Inspector of Prisons (Time to care: what helps women cope in prison February 2025) which notes that the rate of self harm among women in prison is now 8.5 times higher than in men’s jails, and highlights a number of issues which continue to this, which have been reflected in this 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 Delays in transferring women requiring mental health inpatient treatment
Wider context from the report “I am concerned that the ACCT process or system currently in place designed to keep women safe at HMP Styal is not working effectively, and that there is a risk of future deaths if the process is not reconsidered or amended to better suit the needs of this prison. The ACCT process allows for observations of a woman who is at risk of self harm or suicide to keep her safe, but these are not a therapeutic observation and are essentially a check to ensure that the woman is alive and not actively self harming. Mental health input, if a woman is not case loaded to the mental health team, can be minimal, limited to attendance at a case review at best, and this does not allow for an opportunity to improve the woman’s mental health, to reduce the risk of future suicide attempts. Care plans allowing for meaningful activity assist but their effectiveness is limited alongside the prison regime. I acknowledge that prison is not intended to be a therapeutic environment but given the number of women with mental health needs, I am concerned that the current environment or processes will give rise to a risk of future deaths.
My concerns are based on the following points which I heard in evidence:
• HMP Styal is a women’s prison with a high number of self inflicted deaths, compared to the rest of the female estate. I am told by the prison ombudsman that they have the highest number of deaths between January 2022 and January 2025, accounting on my calculation for almost half of the total deaths in the female estate across England. I am aware that there has been one self inflicted death this year to date, and we are only 4 months in;
• I heard evidence from the Head of Safer Prisons and Equality at HMP Styal and the Service Manager for Greater Manchester Mental Health NHS FT, who provide the mental health care in the prison, that the mental health needs of the women detained at Styal are high and can be complex. The latter explained that they receive women from court who have been sent to prison following a criminal act but are essentially awaiting assessment to see whether they should be detained in prison, or in a mental health hospital. The mental health team is then expected to care for the woman for the prolonged period of assessment and awaiting a bed if deemed necessary, something they are not set up to do. It was the view of this witness that Styal was receiving a number of prisoners who are complex and risky and require treatment in a mental health hospital. The process for transfer then takes time and is an additional pressure on the team . The powers of a mental health team in prison are far more restricted, for example, they cannot force medication if needed, and it is reliant on the engagement of prisoners which they frequently do not get. The mental health Trust confirmed that in 2025 to date (29.4.25), 11 prisoners have been referred for a Mental Health Act assessment and of these 11, 8 were accepted for transfer and treatment in a mental health inpatient setting;
• It was the evidence of the Head of Safer Prisons and Equality that they also receive women who are there for a ‘warrant of concern’. A ‘warrant of concern’ is where a woman attends court and is not sentenced at that point but remanded into prison custody due to the Judge having concerns that they are not safe to be released into the community and where it is perceived that they will be safer in custody. This is usually where there are concerns around the woman’s mental health and/or risk to self. This adds pressure on an already stretched resource level in prisons as more resources are generally required to manage such complex individuals; Prison data suggests that HMP Styal have received 7 women on ‘warrants of concern’ since November 2024 to date (April 2025);
• I heard from one witness that a ‘good day’ on one side of the wing would just be one incident of self harm, but there would be frequently multiple incidents;
• The number of number of self harm incidents and ACCT documents open appears to have hardened the prison team to expressions of self harm etc. I heard comments throughout the inquest such as “If I opened an ACCT on every woman who said she was suicidal we’d have loads open”, and “2 incidents of self harm in a morning for one prisoner might seem like a lot but it’s not in the context of Styal”. This may lead to key cases being missed;
• The number of ACCTs open within the prison can be high given the mental health need. I have heard evidence from a number of witnesses as to the pressures that the ACCT process places on staff, primarily due to the high number compared to staffing numbers. The severity of this varied in evidence depending seemingly on whether the member of staff was still with the prison service or had left. The clear consensus however was that the carrying out of ACCT checks, meaningful conversations and documentation of this was difficult whilst also trying to manage the day to day regime. It was accepted by the Head of Safer Prisons and Equality at HMP Styal that the officer on duty on the day of Sarah’s death would have been responsible for 48 checks an hour, and that was not unusual. Evidence from one witness, who has since left the prison, was that as a result of the number of checks required, and the limited resource to do them, checks were frequently missed;
• Meaningful conversations, designed to find out how the person is feeling and check in with them, are being carried out by prison officers with very limited mental health training, with very limited time resource to do this. Mental health training is not mandatory for the officers and can be overlooked due to more pressing, mandatory training.
The jury findings record “Understaffing and a high number of ACCT documents at HMP Styal led to inconsistencies with how staff completed each part of the ACCT process”.
In addition to the evidence heard from the witnesses, I am mindful of the report of HM Chief Inspector of Prisons (Time to care: what helps women cope in prison February 2025) which notes that the rate of self harm among women in prison is now 8.5 times higher than in men’s jails, and highlights a number of issues which continue to this, which have been reflected in this 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 Insufficient staffing capacity to complete ACCT checks and documentation
Wider context from the report “I am concerned that the ACCT process or system currently in place designed to keep women safe at HMP Styal is not working effectively, and that there is a risk of future deaths if the process is not reconsidered or amended to better suit the needs of this prison. The ACCT process allows for observations of a woman who is at risk of self harm or suicide to keep her safe, but these are not a therapeutic observation and are essentially a check to ensure that the woman is alive and not actively self harming. Mental health input, if a woman is not case loaded to the mental health team, can be minimal, limited to attendance at a case review at best, and this does not allow for an opportunity to improve the woman’s mental health, to reduce the risk of future suicide attempts. Care plans allowing for meaningful activity assist but their effectiveness is limited alongside the prison regime. I acknowledge that prison is not intended to be a therapeutic environment but given the number of women with mental health needs, I am concerned that the current environment or processes will give rise to a risk of future deaths.
My concerns are based on the following points which I heard in evidence:
• HMP Styal is a women’s prison with a high number of self inflicted deaths, compared to the rest of the female estate. I am told by the prison ombudsman that they have the highest number of deaths between January 2022 and January 2025, accounting on my calculation for almost half of the total deaths in the female estate across England. I am aware that there has been one self inflicted death this year to date, and we are only 4 months in;
• I heard evidence from the Head of Safer Prisons and Equality at HMP Styal and the Service Manager for Greater Manchester Mental Health NHS FT, who provide the mental health care in the prison, that the mental health needs of the women detained at Styal are high and can be complex. The latter explained that they receive women from court who have been sent to prison following a criminal act but are essentially awaiting assessment to see whether they should be detained in prison, or in a mental health hospital. The mental health team is then expected to care for the woman for the prolonged period of assessment and awaiting a bed if deemed necessary, something they are not set up to do. It was the view of this witness that Styal was receiving a number of prisoners who are complex and risky and require treatment in a mental health hospital. The process for transfer then takes time and is an additional pressure on the team. The powers of a mental health team in prison are far more restricted, for example, they cannot force medication if needed, and it is reliant on the engagement of prisoners which they frequently do not get. The mental health Trust confirmed that in 2025 to date (29.4.25), 11 prisoners have been referred for a Mental Health Act assessment and of these 11, 8 were accepted for transfer and treatment in a mental health inpatient setting;
• It was the evidence of the Head of Safer Prisons and Equality that they also receive women who are there for a ‘warrant of concern’. A ‘warrant of concern’ is where a woman attends court and is not sentenced at that point but remanded into prison custody due to the Judge having concerns that they are not safe to be released into the community and where it is perceived that they will be safer in custody. This is usually where there are concerns around the woman’s mental health and/or risk to self. This adds pressure on an already stretched resource level in prisons as more resources are generally required to manage such complex individuals; Prison data suggests that HMP Styal have received 7 women on ‘warrants of concern’ since November 2024 to date (April 2025);
• I heard from one witness that a ‘good day’ on one side of the wing would just be one incident of self harm, but there would be frequently multiple incidents;
• The number of number of self harm incidents and ACCT documents open appears to have hardened the prison team to expressions of self harm etc. I heard comments throughout the inquest such as “If I opened an ACCT on every woman who said she was suicidal we’d have loads open”, and “2 incidents of self harm in a morning for one prisoner might seem like a lot but it’s not in the context of Styal”. This may lead to key cases being missed;
• The number of ACCTs open within the prison can be high given the mental health need. I have heard evidence from a number of witnesses as to the pressures that the ACCT process places on staff, primarily due to the high number compared to staffing numbers. The severity of this varied in evidence depending seemingly on whether the member of staff was still with the prison service or had left. The clear consensus however was that the carrying out of ACCT checks, meaningful conversations and documentation of this was difficult whilst also trying to manage the day to day regime . It was accepted by the Head of Safer Prisons and Equality at HMP Styal that the officer on duty on the day of Sarah’s death would have been responsible for 48 checks an hour, and that was not unusual. Evidence from one witness, who has since left the prison, was that as a result of the number of checks required, and the limited resource to do them, checks were frequently missed ;
• Meaningful conversations, designed to find out how the person is feeling and check in with them, are being carried out by prison officers with very limited mental health training, with very limited time resource to do this. Mental health training is not mandatory for the officers and can be overlooked due to more pressing, mandatory training.
The jury findings record “Understaffing and a high number of ACCT documents at HMP Styal led to inconsistencies with how staff completed each part of the ACCT process”.
In addition to the evidence heard from the witnesses, I am mindful of the report of HM Chief Inspector of Prisons (Time to care: what helps women cope in prison February 2025) which notes that the rate of self harm among women in prison is now 8.5 times higher than in men’s jails, and highlights a number of issues which continue to this, which have been reflected in this 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 Inconsistent completion of the ACCT process
Wider context from the report “I am concerned that the ACCT process or system currently in place designed to keep women safe at HMP Styal is not working effectively, and that there is a risk of future deaths if the process is not reconsidered or amended to better suit the needs of this prison. The ACCT process allows for observations of a woman who is at risk of self harm or suicide to keep her safe, but these are not a therapeutic observation and are essentially a check to ensure that the woman is alive and not actively self harming. Mental health input, if a woman is not case loaded to the mental health team, can be minimal, limited to attendance at a case review at best, and this does not allow for an opportunity to improve the woman’s mental health, to reduce the risk of future suicide attempts. Care plans allowing for meaningful activity assist but their effectiveness is limited alongside the prison regime. I acknowledge that prison is not intended to be a therapeutic environment but given the number of women with mental health needs, I am concerned that the current environment or processes will give rise to a risk of future deaths.
My concerns are based on the following points which I heard in evidence:
• HMP Styal is a women’s prison with a high number of self inflicted deaths, compared to the rest of the female estate. I am told by the prison ombudsman that they have the highest number of deaths between January 2022 and January 2025, accounting on my calculation for almost half of the total deaths in the female estate across England. I am aware that there has been one self inflicted death this year to date, and we are only 4 months in;
• I heard evidence from the Head of Safer Prisons and Equality at HMP Styal and the Service Manager for Greater Manchester Mental Health NHS FT, who provide the mental health care in the prison, that the mental health needs of the women detained at Styal are high and can be complex. The latter explained that they receive women from court who have been sent to prison following a criminal act but are essentially awaiting assessment to see whether they should be detained in prison, or in a mental health hospital. The mental health team is then expected to care for the woman for the prolonged period of assessment and awaiting a bed if deemed necessary, something they are not set up to do. It was the view of this witness that Styal was receiving a number of prisoners who are complex and risky and require treatment in a mental health hospital. The process for transfer then takes time and is an additional pressure on the team. The powers of a mental health team in prison are far more restricted, for example, they cannot force medication if needed, and it is reliant on the engagement of prisoners which they frequently do not get. The mental health Trust confirmed that in 2025 to date (29.4.25), 11 prisoners have been referred for a Mental Health Act assessment and of these 11, 8 were accepted for transfer and treatment in a mental health inpatient setting;
• It was the evidence of the Head of Safer Prisons and Equality that they also receive women who are there for a ‘warrant of concern’. A ‘warrant of concern’ is where a woman attends court and is not sentenced at that point but remanded into prison custody due to the Judge having concerns that they are not safe to be released into the community and where it is perceived that they will be safer in custody. This is usually where there are concerns around the woman’s mental health and/or risk to self. This adds pressure on an already stretched resource level in prisons as more resources are generally required to manage such complex individuals; Prison data suggests that HMP Styal have received 7 women on ‘warrants of concern’ since November 2024 to date (April 2025);
• I heard from one witness that a ‘good day’ on one side of the wing would just be one incident of self harm, but there would be frequently multiple incidents;
• The number of number of self harm incidents and ACCT documents open appears to have hardened the prison team to expressions of self harm etc. I heard comments throughout the inquest such as “If I opened an ACCT on every woman who said she was suicidal we’d have loads open”, and “2 incidents of self harm in a morning for one prisoner might seem like a lot but it’s not in the context of Styal”. This may lead to key cases being missed;
• The number of ACCTs open within the prison can be high given the mental health need. I have heard evidence from a number of witnesses as to the pressures that the ACCT process places on staff, primarily due to the high number compared to staffing numbers. The severity of this varied in evidence depending seemingly on whether the member of staff was still with the prison service or had left. The clear consensus however was that the carrying out of ACCT checks, meaningful conversations and documentation of this was difficult whilst also trying to manage the day to day regime. It was accepted by the Head of Safer Prisons and Equality at HMP Styal that the officer on duty on the day of Sarah’s death would have been responsible for 48 checks an hour, and that was not unusual. Evidence from one witness, who has since left the prison, was that as a result of the number of checks required, and the limited resource to do them, checks were frequently missed;
• Meaningful conversations, designed to find out how the person is feeling and check in with them, are being carried out by prison officers with very limited mental health training, with very limited time resource to do this. Mental health training is not mandatory for the officers and can be overlooked due to more pressing, mandatory training.
The jury findings record “Understaffing and a high number of ACCT documents at HMP Styal led to inconsistencies with how staff completed each part of the ACCT process ”.
In addition to the evidence heard from the witnesses, I am mindful of the report of HM Chief Inspector of Prisons (Time to care: what helps women cope in prison February 2025) which notes that the rate of self harm among women in prison is now 8.5 times higher than in men’s jails, and highlights a number of issues which continue to this, which have been reflected in this 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 Insufficient mental health team capacity for women awaiting assessment or inpatient beds
Wider context from the report “I am concerned that the ACCT process or system currently in place designed to keep women safe at HMP Styal is not working effectively, and that there is a risk of future deaths if the process is not reconsidered or amended to better suit the needs of this prison. The ACCT process allows for observations of a woman who is at risk of self harm or suicide to keep her safe, but these are not a therapeutic observation and are essentially a check to ensure that the woman is alive and not actively self harming. Mental health input, if a woman is not case loaded to the mental health team, can be minimal, limited to attendance at a case review at best, and this does not allow for an opportunity to improve the woman’s mental health, to reduce the risk of future suicide attempts. Care plans allowing for meaningful activity assist but their effectiveness is limited alongside the prison regime. I acknowledge that prison is not intended to be a therapeutic environment but given the number of women with mental health needs, I am concerned that the current environment or processes will give rise to a risk of future deaths.
My concerns are based on the following points which I heard in evidence:
• HMP Styal is a women’s prison with a high number of self inflicted deaths, compared to the rest of the female estate. I am told by the prison ombudsman that they have the highest number of deaths between January 2022 and January 2025, accounting on my calculation for almost half of the total deaths in the female estate across England. I am aware that there has been one self inflicted death this year to date, and we are only 4 months in;
• I heard evidence from the Head of Safer Prisons and Equality at HMP Styal and the Service Manager for Greater Manchester Mental Health NHS FT, who provide the mental health care in the prison, that the mental health needs of the women detained at Styal are high and can be complex. The latter explained that they receive women from court who have been sent to prison following a criminal act but are essentially awaiting assessment to see whether they should be detained in prison, or in a mental health hospital. The mental health team is then expected to care for the woman for the prolonged period of assessment and awaiting a bed if deemed necessary, something they are not set up to do . It was the view of this witness that Styal was receiving a number of prisoners who are complex and risky and require treatment in a mental health hospital. The process for transfer then takes time and is an additional pressure on the team. The powers of a mental health team in prison are far more restricted, for example, they cannot force medication if needed, and it is reliant on the engagement of prisoners which they frequently do not get. The mental health Trust confirmed that in 2025 to date (29.4.25), 11 prisoners have been referred for a Mental Health Act assessment and of these 11, 8 were accepted for transfer and treatment in a mental health inpatient setting;
• It was the evidence of the Head of Safer Prisons and Equality that they also receive women who are there for a ‘warrant of concern’. A ‘warrant of concern’ is where a woman attends court and is not sentenced at that point but remanded into prison custody due to the Judge having concerns that they are not safe to be released into the community and where it is perceived that they will be safer in custody. This is usually where there are concerns around the woman’s mental health and/or risk to self. This adds pressure on an already stretched resource level in prisons as more resources are generally required to manage such complex individuals; Prison data suggests that HMP Styal have received 7 women on ‘warrants of concern’ since November 2024 to date (April 2025);
• I heard from one witness that a ‘good day’ on one side of the wing would just be one incident of self harm, but there would be frequently multiple incidents;
• The number of number of self harm incidents and ACCT documents open appears to have hardened the prison team to expressions of self harm etc. I heard comments throughout the inquest such as “If I opened an ACCT on every woman who said she was suicidal we’d have loads open”, and “2 incidents of self harm in a morning for one prisoner might seem like a lot but it’s not in the context of Styal”. This may lead to key cases being missed;
• The number of ACCTs open within the prison can be high given the mental health need. I have heard evidence from a number of witnesses as to the pressures that the ACCT process places on staff, primarily due to the high number compared to staffing numbers. The severity of this varied in evidence depending seemingly on whether the member of staff was still with the prison service or had left. The clear consensus however was that the carrying out of ACCT checks, meaningful conversations and documentation of this was difficult whilst also trying to manage the day to day regime. It was accepted by the Head of Safer Prisons and Equality at HMP Styal that the officer on duty on the day of Sarah’s death would have been responsible for 48 checks an hour, and that was not unusual. Evidence from one witness, who has since left the prison, was that as a result of the number of checks required, and the limited resource to do them, checks were frequently missed;
• Meaningful conversations, designed to find out how the person is feeling and check in with them, are being carried out by prison officers with very limited mental health training, with very limited time resource to do this. Mental health training is not mandatory for the officers and can be overlooked due to more pressing, mandatory training.
The jury findings record “Understaffing and a high number of ACCT documents at HMP Styal led to inconsistencies with how staff completed each part of the ACCT process”.
In addition to the evidence heard from the witnesses, I am mindful of the report of HM Chief Inspector of Prisons (Time to care: what helps women cope in prison February 2025) which notes that the rate of self harm among women in prison is now 8.5 times higher than in men’s jails, and highlights a number of issues which continue to this, which have been reflected in this 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 Insufficient mental health training and time for prison officers conducting meaningful ACCT conversations
Wider context from the report “I am concerned that the ACCT process or system currently in place designed to keep women safe at HMP Styal is not working effectively, and that there is a risk of future deaths if the process is not reconsidered or amended to better suit the needs of this prison. The ACCT process allows for observations of a woman who is at risk of self harm or suicide to keep her safe, but these are not a therapeutic observation and are essentially a check to ensure that the woman is alive and not actively self harming. Mental health input, if a woman is not case loaded to the mental health team, can be minimal, limited to attendance at a case review at best, and this does not allow for an opportunity to improve the woman’s mental health, to reduce the risk of future suicide attempts. Care plans allowing for meaningful activity assist but their effectiveness is limited alongside the prison regime. I acknowledge that prison is not intended to be a therapeutic environment but given the number of women with mental health needs, I am concerned that the current environment or processes will give rise to a risk of future deaths.
My concerns are based on the following points which I heard in evidence:
• HMP Styal is a women’s prison with a high number of self inflicted deaths, compared to the rest of the female estate. I am told by the prison ombudsman that they have the highest number of deaths between January 2022 and January 2025, accounting on my calculation for almost half of the total deaths in the female estate across England. I am aware that there has been one self inflicted death this year to date, and we are only 4 months in;
• I heard evidence from the Head of Safer Prisons and Equality at HMP Styal and the Service Manager for Greater Manchester Mental Health NHS FT, who provide the mental health care in the prison, that the mental health needs of the women detained at Styal are high and can be complex. The latter explained that they receive women from court who have been sent to prison following a criminal act but are essentially awaiting assessment to see whether they should be detained in prison, or in a mental health hospital. The mental health team is then expected to care for the woman for the prolonged period of assessment and awaiting a bed if deemed necessary, something they are not set up to do. It was the view of this witness that Styal was receiving a number of prisoners who are complex and risky and require treatment in a mental health hospital. The process for transfer then takes time and is an additional pressure on the team. The powers of a mental health team in prison are far more restricted, for example, they cannot force medication if needed, and it is reliant on the engagement of prisoners which they frequently do not get. The mental health Trust confirmed that in 2025 to date (29.4.25), 11 prisoners have been referred for a Mental Health Act assessment and of these 11, 8 were accepted for transfer and treatment in a mental health inpatient setting;
• It was the evidence of the Head of Safer Prisons and Equality that they also receive women who are there for a ‘warrant of concern’. A ‘warrant of concern’ is where a woman attends court and is not sentenced at that point but remanded into prison custody due to the Judge having concerns that they are not safe to be released into the community and where it is perceived that they will be safer in custody. This is usually where there are concerns around the woman’s mental health and/or risk to self. This adds pressure on an already stretched resource level in prisons as more resources are generally required to manage such complex individuals; Prison data suggests that HMP Styal have received 7 women on ‘warrants of concern’ since November 2024 to date (April 2025);
• I heard from one witness that a ‘good day’ on one side of the wing would just be one incident of self harm, but there would be frequently multiple incidents;
• The number of number of self harm incidents and ACCT documents open appears to have hardened the prison team to expressions of self harm etc. I heard comments throughout the inquest such as “If I opened an ACCT on every woman who said she was suicidal we’d have loads open”, and “2 incidents of self harm in a morning for one prisoner might seem like a lot but it’s not in the context of Styal”. This may lead to key cases being missed;
• The number of ACCTs open within the prison can be high given the mental health need. I have heard evidence from a number of witnesses as to the pressures that the ACCT process places on staff, primarily due to the high number compared to staffing numbers. The severity of this varied in evidence depending seemingly on whether the member of staff was still with the prison service or had left. The clear consensus however was that the carrying out of ACCT checks, meaningful conversations and documentation of this was difficult whilst also trying to manage the day to day regime. It was accepted by the Head of Safer Prisons and Equality at HMP Styal that the officer on duty on the day of Sarah’s death would have been responsible for 48 checks an hour, and that was not unusual. Evidence from one witness, who has since left the prison, was that as a result of the number of checks required, and the limited resource to do them, checks were frequently missed;
• Meaningful conversations, designed to find out how the person is feeling and check in with them, are being carried out by prison officers with very limited mental health training, with very limited time resource to do this. Mental health training is not mandatory for the officers and can be overlooked due to more pressing, mandatory training.
The jury findings record “Understaffing and a high number of ACCT documents at HMP Styal led to inconsistencies with how staff completed each part of the ACCT process”.
In addition to the evidence heard from the witnesses, I am mindful of the report of HM Chief Inspector of Prisons (Time to care: what helps women cope in prison February 2025) which notes that the rate of self harm among women in prison is now 8.5 times higher than in men’s jails, and highlights a number of issues which continue to this, which have been reflected in this inquest.
” Open source report
×
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 weekly one-to-one upskilling sessions for case coordinators requiring additional support.
Verbatim wording from the response “In the light of your concerns and on the basis of other feedback and learning, the Governor of Styal is taking further steps to ensure meaningful support actions are identified at each case review and implemented. Case reviews are subject to quality assurance processes, and any case coordinators identified as needing additional support receive weekly one-to-one upskilling sessions. Furthermore, through the support of the group safety team, learning and best practice identified from other cases within the women’s estate is shared and applied at Styal to facilitate continuous improvement.” Source location Joint Response from Ministry of Justice and HMPPS
Open published response
×
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 Review the process for involving mental health services in ACCT cases.
Verbatim wording from the response “response to your concerns, the Governor of Styal and the mental healthcare provider will be reviewing the current process for involving mental health services in such cases.” Source location Joint Response from Ministry of Justice and HMPPS
Open published response
×
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 Expand the local safety team by introducing a safety analyst and second safety hub manager to support ACCT quality assurance and staff upskilling.
Verbatim wording from the response “All prisoners at Styal who are subject to ACCT case management and have observation levels set at more than one every two hours are located on the residential wings, as opposed to the dormitories, where there are more staff available to conduct the observations. Additionally, women who are being supported through the ACCT process are discussed during the Senior Management Team morning meeting, and where appropriate more staff are deployed to areas in which more such individuals are located to ensure that there is time for meaningful interactions with them. In support of this the local safety team is being expanded with the introduction of a safety analyst and a second safety hub manager, who will assist in the ACCT quality assurance process and provide any necessary upskilling for staff.” Source location Joint Response from Ministry of Justice and HMPPS
Open published response
×
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 Ensure meaningful support actions are identified and implemented at each ACCT case review.
Verbatim wording from the response “In the light of your concerns and on the basis of other feedback and learning, the Governor of Styal is taking further steps to ensure meaningful support actions are identified at each case review and implemented. Case reviews are subject to quality assurance processes, and any case coordinators identified as needing additional support receive weekly one-to-one upskilling sessions. Furthermore, through the support of the group safety team, learning and best practice identified from other cases within the women’s estate is shared and applied at Styal to facilitate continuous improvement.” Source location Joint Response from Ministry of Justice and HMPPS
Open published response
×
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 a local safety summit and upskill staff on suicide and self-harm risks, triggers and protective factors.
Verbatim wording from the response “I recognise your concerns that Styal has had a higher number of self-inflicted deaths than other establishments in the women’s estate, and would like to reassure you that following the cluster of self-inflicted deaths, support has been provided to the prison from the national safety team as part of the HMPPS cluster death support process. This has included assistance with delivering a local safety summit and upskilling for staff on a range of issues, including awareness of risks, triggers and protective factors for suicide and self-harm.” Source location Joint Response from Ministry of Justice and HMPPS
Open published response
18 Feb 2025 Ronald Bainborough · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 3 Delays in scheduling police execution of s135(1) warrants View source Delays in obtaining Magistrates Court hearings for s135(1) warrant applications View source Lack of an official fast-track procedure for s135(1) warrants 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
Ronald Bainborough · 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 Bainborough lived in supported living accommodation and had schizophrenia, substance misuse, malnutrition and a history of disengagement from mental health and primary care services. A warrant under section 135(1) of the Mental Health Act was sought after he refused assessment, but there were delays before it was granted and arrangements were made for execution; he was admitted to hospital with severe malnutrition before the warrant was executed and died from community acquired pneumonia and malnutrition. The concerns identified included the time taken to apply for and execute warrants, the absence of an official fast-track procedure, and the resulting risk of fatal harm to individuals awaiting assessment.
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 Delays in scheduling police execution of s135(1) warrants
Wider context from the report “(1) During the Inquest, evidence was heard from 2 consultant psychiatrists and an Approved Mental Health Act Professional (AMHP) regarding the timescales for applying for and executing s135(1) warrants. All of them had concerns about the time taken for a warrant to be issued and executed
(2) The warrant application was submitted to the Magistrates Court on 18 August 2023, the hearing took place on 23 August and it was intended that the warrant would be executed on 7 September 2023. This was a timescale of 20 days. The jury was told that this timescale was typical of the time taken to apply for and execute a s135(1) warrant in the experience of the professionals giving evidence at the Inquest.
(3) Applications for a warrant are heard at Westminster and Uxbridge Magistrates Courts which consider applications from all 32 London Boroughs. There are a limited number of video hearing slots, so AMPH teams may have to wait several days for a hearing.
(4) Once a warrant has been issued, an appointment then needs to be arranged for police officers to execute the warrant. The evidence before the court was that it would generally take in the region of 10 days for an appointment to be scheduled.
(5) There is no official fast track procedure. Consequently, there is a risk of harm to the individual and others during the time taken for a warrant to be granted and executed.
(6) As individuals have been identified as requiring assessment under the Mental Health Act, the risk of potential harm is recognised. In the absence of treatment, there is an ongoing risk that individuals will harm themselves or others before the warrant can be executed. This includes a risk of fatal harm.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Delays in obtaining Magistrates Court hearings for s135(1) warrant applications
Wider context from the report “(1) During the Inquest, evidence was heard from 2 consultant psychiatrists and an Approved Mental Health Act Professional (AMHP) regarding the timescales for applying for and executing s135(1) warrants. All of them had concerns about the time taken for a warrant to be issued and executed
(2) The warrant application was submitted to the Magistrates Court on 18 August 2023, the hearing took place on 23 August and it was intended that the warrant would be executed on 7 September 2023. This was a timescale of 20 days. The jury was told that this timescale was typical of the time taken to apply for and execute a s135(1) warrant in the experience of the professionals giving evidence at the Inquest.
(3) Applications for a warrant are heard at Westminster and Uxbridge Magistrates Courts which consider applications from all 32 London Boroughs. There are a limited number of video hearing slots, so AMPH teams may have to wait several days for a hearing.
(4) Once a warrant has been issued, an appointment then needs to be arranged for police officers to execute the warrant. The evidence before the court was that it would generally take in the region of 10 days for an appointment to be scheduled.
(5) There is no official fast track procedure. Consequently, there is a risk of harm to the individual and others during the time taken for a warrant to be granted and executed.
(6) As individuals have been identified as requiring assessment under the Mental Health Act, the risk of potential harm is recognised. In the absence of treatment, there is an ongoing risk that individuals will harm themselves or others before the warrant can be executed. This includes a risk of fatal harm.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Lack of an official fast-track procedure for s135(1) warrants
Wider context from the report “(1) During the Inquest, evidence was heard from 2 consultant psychiatrists and an Approved Mental Health Act Professional (AMHP) regarding the timescales for applying for and executing s135(1) warrants. All of them had concerns about the time taken for a warrant to be issued and executed
(2) The warrant application was submitted to the Magistrates Court on 18 August 2023, the hearing took place on 23 August and it was intended that the warrant would be executed on 7 September 2023. This was a timescale of 20 days. The jury was told that this timescale was typical of the time taken to apply for and execute a s135(1) warrant in the experience of the professionals giving evidence at the Inquest.
(3) Applications for a warrant are heard at Westminster and Uxbridge Magistrates Courts which consider applications from all 32 London Boroughs. There are a limited number of video hearing slots, so AMPH teams may have to wait several days for a hearing.
(4) Once a warrant has been issued, an appointment then needs to be arranged for police officers to execute the warrant. The evidence before the court was that it would generally take in the region of 10 days for an appointment to be scheduled.
(5) There is no official fast track procedure. Consequently, there is a risk of harm to the individual and others during the time taken for a warrant to be granted and executed.
(6) As individuals have been identified as requiring assessment under the Mental Health Act, the risk of potential harm is recognised. In the absence of treatment, there is an ongoing risk that individuals will harm themselves or others before the warrant can be executed. This includes a risk of fatal harm.
” Open source report
18 Feb 2025 Zahra Sharif Mohamed · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 4 Reliance on encouraging voluntary return before applying for a warrant View source Risk of patients harming themselves or others before s135(2) warrant execution View source Delays in obtaining and executing s135(2) warrants View source Discouragement of urgent in-person applications for s135(2) warrants 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
Zahra Sharif Mohamed · 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
Zahra Sharif Mohamed, who had been detained under the Mental Health Act and sent on home leave, expressed suicidal thoughts and threatened to jump from the balcony of her fifth-floor flat. She jumped from the balcony on 12 October 2022 and died at the scene. The principal concerns were that a warrant to return her to hospital was not applied for, and that delays in obtaining and executing such warrants create a risk of patients harming themselves or others, including fatal harm.
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 Reliance on encouraging voluntary return before applying for a warrant
Wider context from the report “(1) It was accepted that a s135(2) warrant should have been applied for on 4 October 2022. However, if an application had been submitted to the magistrates’ court that day, it is unlikely that the warrant would have been executed before Mrs Mohamed’s death. In evidence, I was informed by a number of mental health professionals that the time taken for a s135(2) warrant to be obtained from the magistrates’ court and executed by the police was in the region of 2 weeks.
(2) The process for obtaining a warrant is that an application has to be made for a video hearing at either Uxbridge or Westminster Magistrates’ Courts. It could take several days for a hearing to be arranged as the courts consider applications from all 32 London Boroughs. Once the Magistrates issued a warrant, an appointment would then be arranged for the police to execute the warrant.
(3) I was informed that a 2-week timescale for obtaining s135(2) warrants was still the case in the summer of 2024.
(4) I also heard evidence that the mental health team could attend Highbury Corner Magistrates’ Court in person to apply for a warrant in urgent cases but that they were actively discouraged from using this process by the court.
(5) The court heard that the process and timescale for issuing and executing warrants had led to the hospital team adopting a practice of asking the community team to encourage a patient to return to hospital voluntarily before making an application for a warrant .
(6) There is an ongoing risk that patients will harm themselves or others in the period before the warrant can be executed. This includes a risk of fatal harm.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Risk of patients harming themselves or others before s135(2) warrant execution
Wider context from the report “(1) It was accepted that a s135(2) warrant should have been applied for on 4 October 2022. However, if an application had been submitted to the magistrates’ court that day, it is unlikely that the warrant would have been executed before Mrs Mohamed’s death. In evidence, I was informed by a number of mental health professionals that the time taken for a s135(2) warrant to be obtained from the magistrates’ court and executed by the police was in the region of 2 weeks.
(2) The process for obtaining a warrant is that an application has to be made for a video hearing at either Uxbridge or Westminster Magistrates’ Courts. It could take several days for a hearing to be arranged as the courts consider applications from all 32 London Boroughs. Once the Magistrates issued a warrant, an appointment would then be arranged for the police to execute the warrant.
(3) I was informed that a 2-week timescale for obtaining s135(2) warrants was still the case in the summer of 2024.
(4) I also heard evidence that the mental health team could attend Highbury Corner Magistrates’ Court in person to apply for a warrant in urgent cases but that they were actively discouraged from using this process by the court.
(5) The court heard that the process and timescale for issuing and executing warrants had led to the hospital team adopting a practice of asking the community team to encourage a patient to return to hospital voluntarily before making an application for a warrant.
(6) There is an ongoing risk that patients will harm themselves or others in the period before the warrant can be executed. This includes a risk of fatal harm.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Delays in obtaining and executing s135(2) warrants
Wider context from the report “(1) It was accepted that a s135(2) warrant should have been applied for on 4 October 2022. However, if an application had been submitted to the magistrates’ court that day, it is unlikely that the warrant would have been executed before Mrs Mohamed’s death. In evidence, I was informed by a number of mental health professionals that the time taken for a s135(2) warrant to be obtained from the magistrates’ court and executed by the police was in the region of 2 weeks .
(2) The process for obtaining a warrant is that an application has to be made for a video hearing at either Uxbridge or Westminster Magistrates’ Courts. It could take several days for a hearing to be arranged as the courts consider applications from all 32 London Boroughs. Once the Magistrates issued a warrant, an appointment would then be arranged for the police to execute the warrant.
(3) I was informed that a 2-week timescale for obtaining s135(2) warrants was still the case in the summer of 2024 .
(4) I also heard evidence that the mental health team could attend Highbury Corner Magistrates’ Court in person to apply for a warrant in urgent cases but that they were actively discouraged from using this process by the court.
(5) The court heard that the process and timescale for issuing and executing warrants had led to the hospital team adopting a practice of asking the community team to encourage a patient to return to hospital voluntarily before making an application for a warrant.
(6) There is an ongoing risk that patients will harm themselves or others in the period before the warrant can be executed. This includes a risk of fatal harm.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Discouragement of urgent in-person applications for s135(2) warrants
Wider context from the report “(1) It was accepted that a s135(2) warrant should have been applied for on 4 October 2022. However, if an application had been submitted to the magistrates’ court that day, it is unlikely that the warrant would have been executed before Mrs Mohamed’s death. In evidence, I was informed by a number of mental health professionals that the time taken for a s135(2) warrant to be obtained from the magistrates’ court and executed by the police was in the region of 2 weeks.
(2) The process for obtaining a warrant is that an application has to be made for a video hearing at either Uxbridge or Westminster Magistrates’ Courts. It could take several days for a hearing to be arranged as the courts consider applications from all 32 London Boroughs. Once the Magistrates issued a warrant, an appointment would then be arranged for the police to execute the warrant.
(3) I was informed that a 2-week timescale for obtaining s135(2) warrants was still the case in the summer of 2024.
(4) I also heard evidence that the mental health team could attend Highbury Corner Magistrates’ Court in person to apply for a warrant in urgent cases but that they were actively discouraged from using this process by the court .
(5) The court heard that the process and timescale for issuing and executing warrants had led to the hospital team adopting a practice of asking the community team to encourage a patient to return to hospital voluntarily before making an application for a warrant.
(6) There is an ongoing risk that patients will harm themselves or others in the period before the warrant can be executed. This includes a risk of fatal harm.
” Open source report
7 Feb 2025 Anthony Binfield and 2 others · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 14 Inadequate basic training, supervision and mentoring of prison staff View source Inadequate prison and healthcare staffing levels View source Failure to act with candour in post-death investigations View source Use of inaccessible email channels for risk pertinent information View source Failure to identify and share risk pertinent information between prison and healthcare staff View source Insufficient safety scrutiny during prison contract transfer View source Failure to reduce isolation of foreign national prisoners View source Failure to embed learning from deaths and monitor safety culture View source Failure to provide a nurse during night state View source Unreliable and delayed access to interpretation services for foreign national prisoners View source Lack of an effective system for gathering, retaining, reviewing and disclosing investigation material View source Failure to retain sufficient experienced prison and healthcare staff View source Lack of effective NPS-specific drug policy View source Lack of a formal prison-to-prison transfer management system 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
Anthony Binfield and 2 others · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Anthony Binfield, David William Richards and Rolandas Karbauskas died at HMP Lowdham Grange in March 2023 after using ligatures; Anthony’s and Rolandas’s deaths were suicides, while David’s death was accidental. The report identified missed opportunities to recognise and share risk information, shortcomings in prison and healthcare staffing, training and systems, and concerns about prisoner transfers, isolation, the prison contract transfer, and learning from previous 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 Inadequate basic training, supervision and mentoring of prison staff
Wider context from the report “All of the prison staff had completed the ITC programme, and yet there was widespread evidence of failures to do the basics . Staff failed to ensure the welfare of prisoners at roll count, failed to challenge flagrant breaches of Prison rules such as passing items under cell doors, and did not know how to properly deal with obscured cell observation hatches.
This calls into question the adequacy of their basic training, and the system for supervision and mentoring during the early years of practice.
” 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 prison and healthcare staffing levels
Wider context from the report “The inadequate prison and healthcare staffing levels led to a restricted regime and healthcare provision. The prison was unable to offer keywork to all men, and the mental health team could no longer offer a named nurse service. Both of these aspects of care are fundamental to supporting the most vulnerable prisoners.
” 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 act with candour in post-death investigations
Wider context from the report “The Healthcare Trust are subject to a statutory duty of candour. HMPPS, Serco and Sodexo failed to embrace the same ethos during these investigations.
” 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 Use of inaccessible email channels for risk pertinent information
Wider context from the report “I am also concerned by the use of email to convey risk pertinent information . In this case, prison staff communicated their concerns about Anthony’s mental health to individual nursing Sodexo email inboxes, which the nurses were not expected to regularly access . The use of email means that such concerns are not accessible to other members of staff as they would be if they were recorded in PNOMIS or Systemone.
” 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 identify and share risk pertinent information between prison and healthcare staff
Wider context from the report “There was a complete breakdown in the system of risk identification and information sharing . Prison and healthcare staff did not routinely consider information captured within the electronic systems , nor did they update the systems with risk pertinent information gathered during interactions with the prisoners .
” 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 safety scrutiny during prison contract transfer
Wider context from the report “Safety was not front and centre of the Mobilisation and Transfer project.
” 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 reduce isolation of foreign national prisoners
Wider context from the report “I heard evidence that the Big Word translation service did not work on multiple occasions across multiple sites within the prison. Staff gave evidence that even when the system did connect, they could be waiting in a queue for up to an hour to access an appropriate interpreter.
There was no plan to seek to reduce Rolandas’ obvious isolation , and seemingly no provision for expediting his induction so that he could be housed with fellow Lithuanian speakers .
” 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 embed learning from deaths and monitor safety culture
Wider context from the report “I heard evidence that many of the contributory factors leading to the deaths of Anthony, David and Rolandas, had been raised as issues in the investigations following previous deaths in custody at HMP Lowdham Grange.
While Serco no longer manage HMP Lowdham Grange, they continue to manage prisons, and there is a risk of future deaths if the organisation is unable to create a robust culture of seeking to identify issues early, adopt learning, and continually monitor culture to ensure any action taken is embedded to reduce the 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 a nurse during night state
Wider context from the report “For months prior to the deaths, the Trust failed to fulfil its commissioned obligations to provide a nurse during night state . Prison staff have only basic first aid training and lacked the expertise of a medical professional when attempting to provide CPR to Anthony.
” 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 Unreliable and delayed access to interpretation services for foreign national prisoners
Wider context from the report “I heard evidence that the Big Word translation service did not work on multiple occasions across multiple sites within the prison . Staff gave evidence that even when the system did connect, they could be waiting in a queue for up to an hour to access an appropriate interpreter .
There was no plan to seek to reduce Rolandas’ obvious isolation, and seemingly no provision for expediting his induction so that he could be housed with fellow Lithuanian speakers.
” 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 an effective system for gathering, retaining, reviewing and disclosing investigation material
Wider context from the report “HMPPS have no effective system for gathering, retaining, reviewing and disclosing potentially relevant material so that the issues relevant to death can be identified and learning put in place.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to retain sufficient experienced prison and healthcare staff
Wider context from the report “I am concerned by the failure to retain experienced prison officers and healthcare staff . The private prison operator and the Authority were focused on the number of staff, rather than the skill sets or experience of the staffing body as a whole .
” 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 effective NPS-specific drug policy
Wider context from the report “There is no requirement for prisons to have an NPS specific drug policy and I am concerned that generic drug reduction strategies are ineffective against this particular threat .
NPS is highly dangerous and carries a risk of death. I am concerned that more young men will die in custody as a result of NPS use.
” 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 prison-to-prison transfer management system
Wider context from the report “I heard evidence that there is no formal policy framework or system for managing the progress of prison-to-prison transfers , including a lack of expected response times or formal escalation plan if a prison fails to provide any response.
” Open source report
22 Jan 2025 Nathan Harry SHEPHERD · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 9 Failure to ensure key risk documents are completed by probation staff familiar with the case history View source Lack of staff training for incidents of residents barricading themselves into rooms View source Failure to provide Approved Premises staff with accurate and complete risk information View source Failure to implement a policy for incidents of residents barricading themselves into rooms at Approved Premises View source Failure of the prison-to-probation process to share and locate key risk information View source Continuing ligature points in Approved Premises View source Lack of a clear Approved Premises policy controlling furniture that can be used to create barricades View source Failure to verify agency staff competence to deliver CPR and First Aid View source Failure to establish how the barricade-incident policy links with Police policies View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Nathan Harry SHEPHERD · 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
Nathan Harry Shepherd died in hospital on 16 January 2024 after being found suspended from a ligature in his room at approved premises, following an unsuccessful attempt to gain immediate entry because the room had been barricaded. The inquest concluded that the death was suicide, with medical cause of death recorded as hypoxic brain injury and hanging. Concerns included the lack of policies and training for barricaded-room incidents, movable furniture that enabled barricading, ligature points, inadequate assurance of agency staff first-aid and CPR capability, and ineffective sharing of risk information.
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 key risk documents are completed by probation staff familiar with the case history
Wider context from the report “7. The inquest heard evidence that the information shared with the Approved Premises staff by other probation staff was not accurate and did not give a full picture of risk. This was in part due to the fact that it appeared key documents were being regularly completed by probation staff who were not the allocated probation officer and so were unfamiliar with the history .
” 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 for incidents of residents barricading themselves into rooms
Wider context from the report “1. The inquest heard evidence that the Probation Service had no policy to cover incidents of residents barricading themselves into rooms at Approved Premises. This meant that staff did not have training on how to deal with a situation . The inquest was told that the Probation Service were now developing such a policy but it had not been signed off or rolled out to staff.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to provide Approved Premises staff with accurate and complete risk information
Wider context from the report “7. The inquest heard evidence that the information shared with the Approved Premises staff by other probation staff was not accurate and did not give a full picture of risk . This was in part due to the fact that it appeared key documents were being regularly completed by probation staff who were not the allocated probation officer and so were unfamiliar with the history.
” 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 a policy for incidents of residents barricading themselves into rooms at Approved Premises
Wider context from the report “1. The inquest heard evidence that the Probation Service had no policy to cover incidents of residents barricading themselves into rooms at Approved Premises . This meant that staff did not have training on how to deal with a situation. The inquest was told that the Probation Service were now developing such a policy but it had not been signed off or rolled out to staff .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure of the prison-to-probation process to share and locate key risk information
Wider context from the report “6. Evidence from Probation and Prison staff showed a lack of understanding of how the prison system could update the probation system and where that information could be found . This meant that key information was not shared effectively creating a risk that probation staff in the community would not have a full picture of 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 Continuing ligature points in Approved Premises
Wider context from the report “4. The ████████ was a ligature point. Such ligature points remained in the Approved premises . It was unclear if changes could be made to reduce the risk they presented .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear Approved Premises policy controlling furniture that can be used to create barricades
Wider context from the report “3. The evidence before the inquest was that Mr Shepherd was able to barricade himself with relative ease due to the mobility of the furniture in his room. The Approved Premises had no clear policy regarding furniture which meant that furniture could be used to create a barricade with relative ease .
” 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 verify agency staff competence to deliver CPR and First Aid
Wider context from the report “5. Agency staff were used under a national contract. The evidence before the inquest was that at the time of Mr Shepherd’s death there was no policy for ensuring they could deliver CPR / First Aid . It was part of the national contract that they should be so trained but there were no checks to ensure that this part of the contract was being followed . The evidence at the inquest was that the agency worker in place on the night did not appear able to deliver CPR .
” 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 how the barricade-incident policy links with Police policies
Wider context from the report “2. A copy of the draft policy was available to the inquest but it was unclear what if any discussion there had been with Police Forces and how it would link in with Police policies such as the GMP Right Care Policy .
” Open source report
×
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 Introduce anti-ligature-compliant fire detection equipment across the Approved Premises estate.
Verbatim wording from the response “Fire detection equipment that is designed to meet anti-ligature standards is available and is being introduced across the Approved Premises estate. Facilities Management providers are aware of the need for any replacement fittings to meet the anti ligature standards. In light of your concern this has now been raised with the AP Maintenance Strategy Group to undertake a review of existing equipment with a view to ensuring this replacement work is incorporated into future maintenance programmes” Source location Response from HMPPS
Open published response
×
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 Complete sign-off, issue barricade guidance to Approved Premises staff, and obtain their acknowledgement of receipt and understanding.
Verbatim wording from the response “The Barricade Guidance referred to in evidence given at the Inquest hearing has now been finalised and is going through the final stages of sign off prior to issue to all approved premises staff on 1st August 2025. This guidance will form part of the Safe Working Practice document and staff will be required to acknowledge receipt and their understanding by the end of September 2025. This will be overseen by all Approved Premises Managers.” Source location Response from HMPPS
Open published response
×
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 Collate Approved Premises furniture information through local estates boards to support renovation planning.
Verbatim wording from the response “The policy on furniture in Approved Premises is set out in a furniture specification which states that beds and wardrobes should be fixed (although this does not apply to chairs). This specification is currently being applied across all Approved Premises but it is acknowledged that this is a rolling programme and is subject to funding for renovation programmes. The Probation Estates Team are currently collating information on furniture through local estates boards and every effort will be made to prioritise funding to replace moveable furniture with fixed furniture.” Source location Response from HMPPS
Open published response
×
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 Review existing fire detection equipment and incorporate anti-ligature replacement work into future maintenance programmes.
Verbatim wording from the response “Fire detection equipment that is designed to meet anti-ligature standards is available and is being introduced across the Approved Premises estate. Facilities Management providers are aware of the need for any replacement fittings to meet the anti ligature standards. In light of your concern this has now been raised with the AP Maintenance Strategy Group to undertake a review of existing equipment with a view to ensuring this replacement work is incorporated into future maintenance programmes” Source location Response from HMPPS
Open published response
×
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 Apply the fixed-bed and fixed-wardrobe furniture specification across Approved Premises through a rolling renovation programme.
Verbatim wording from the response “The policy on furniture in Approved Premises is set out in a furniture specification which states that beds and wardrobes should be fixed (although this does not apply to chairs). This specification is currently being applied across all Approved Premises but it is acknowledged that this is a rolling programme and is subject to funding for renovation programmes. The Probation Estates Team are currently collating information on furniture through local estates boards and every effort will be made to prioritise funding to replace moveable furniture with fixed furniture.” Source location Response from HMPPS
Open published response
×
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 Monitor external agency compliance with contractual requirements for HMPPS-standard training, including First Aid, CPR and defibrillator use.
Verbatim wording from the response “The Double Waking Night Cover contract with external agencies is due to come to an end in March 2026 and thereafter night shifts at Approved Premises will no longer be contracted out and will be brought in house. This will ensure that all staff will be trained in accordance with HMPPS requirements, which includes First Aid, CPR and use of the defibrillator. There are already pilots in place across the country looking to this new arrangement. Where this service is still being delivered by external agencies, it will be part of the contract management process to monitor compliance with the contractual term that requires the agency staff to be fully trained to the standard required by HMPPS.” Source location Response from HMPPS
Open published response
×
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 Bring Approved Premises night shifts in house when the external Double Waking Night Cover contract ends in March 2026.
Verbatim wording from the response “The Double Waking Night Cover contract with external agencies is due to come to an end in March 2026 and thereafter night shifts at Approved Premises will no longer be contracted out and will be brought in house. This will ensure that all staff will be trained in accordance with HMPPS requirements, which includes First Aid, CPR and use of the defibrillator. There are already pilots in place across the country looking to this new arrangement. Where this service is still being delivered by external agencies, it will be part of the contract management process to monitor compliance with the contractual term that requires the agency staff to be fully trained to the standard required by HMPPS.” Source location Response from HMPPS
Open published response
×
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 Use the new digital referral process to combine prison and probation information, including custodial behaviour and suicide and self-harm risk, for Approved Premises assessments.
Verbatim wording from the response “There is now a new digital referral process in place that pulls information from both prison and probation systems as part of the referral process, allowing for much more accurate and timely sharing of information. The information is pulled directly from CNOMIS into a live referral document and this is reviewed by the practitioner and also the AP Manager who assesses the referral. The information includes custodial behaviour and issues around suicide and self harm risk.” Source location Response from HMPPS
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 addressing the concern locally was assigned to Greater Manchester Police.
Verbatim wording from the response “The Ministry of Justice is not currently a party to the National Partnership Agreement which supports working together to ensure people get the right support. At a local level your concern has been raised with Greater Manchester Police.” Source location Response from HMPPS
Open published response
8 Jan 2025 Matthew Brierley · Prevention of Future Deaths report Cumbria
View report summary
Concerns raised 4 Failure to provide proactive contact and support to men at elevated suicide risk View source Markedly elevated suicide risk among men in comparable circumstances View source Failure to undertake detailed individual risk assessment when applying bail conditions View source Delays in examination of devices and case decisions prolonging risk during bail 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
Matthew Brierley · 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 Brierley died in the car park of Buttermere Court Hotel on 24 April 2024, after being arrested, bailed and placed under conditions that prevented him from living at home or having unsupervised contact with his children and stepdaughter. The inquest concluded that his death was suicide. Concerns included the potentially prolonged period before decisions were made about his devices and case, the use of standard bail conditions without an apparent specific risk assessment, and the lack of proactive follow-up support after his release on bail.
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 proactive contact and support to men at elevated suicide risk
Wider context from the report “(3) Police acknowledged the increased risk and completed a standard assessment form when Matthew was released - he denied any risk and also declined referral to Liaison and Diversion service. A Family Contact Officer was also appointed but the onus remained on Matthew to seek help and there was no proactive contact which might have been helpful as men in Matthew's situation are less likely to seek help due to feelings of shame and embarrassment .
” 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 Markedly elevated suicide risk among men in comparable circumstances
Wider context from the report “(1) It is recognized that men in Matthew's circumstances are at a markedly elevated risk of suicide . Several papers refer to this - I found Kothari et al (Journal of Forensic and Legal Medicine, July 2021) particularly informative. They quote 3.2% of those arrested in operation Notarise committing suicide and explore reasons why this group is particularly vulnerable.
” 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 undertake detailed individual risk assessment when applying bail conditions
Wider context from the report “(2) I was told that when released on bail Matthew was informed that examination of devices and a decision in his case might take up to 18 months. Being suspended from work and unable to live at home removed normality and stability from Matthew and likely impaired his ability to cope with his situation. The length of time taken to reach a decision seems excessive, prolonging the time Matthew would be at risk. I was told devices can be "triaged" within a matter of days or more quickly, surely ceases such as this should be dealt with more expeditiously? It seems that "standard" bail conditions are applied but I am not aware of any suggestion of a specific risk to Matthew's stepdaughter , might a more detailed individual assessment of risk be helpful? I should record that Matthew's phone was examined after his death and that images found were not of a grade that would have led to a prosecution.
” 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 examination of devices and case decisions prolonging risk during bail
Wider context from the report “(2) I was told that when released on bail Matthew was informed that examination of devices and a decision in his case might take up to 18 months. Being suspended from work and unable to live at home removed normality and stability from Matthew and likely impaired his ability to cope with his situation. The length of time taken to reach a decision seems excessive, prolonging the time Matthew would be at risk . I was told devices can be "triaged" within a matter of days or more quickly , surely ceases such as this should be dealt with more expeditiously? It seems that "standard" bail conditions are applied but I am not aware of any suggestion of a specific risk to Matthew's stepdaughter, might a more detailed individual assessment of risk be helpful? I should record that Matthew's phone was examined after his death and that images found were not of a grade that would have led to a prosecution.
” Open source report
20 Dec 2024 Haydar Jefferies · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 11 Unavailability of medication for acute mental health symptoms overnight View source Unavailability of clinical mental health provision outside weekday office hours View source Failure to record prisoner welfare information provided in telephone calls View source Lack of a composite 24-hour information document for clinicians reviewing CSU prisoners View source Lack of custody staff training to recognise red flags of declining mental health View source Failure to verify completion of requested mental health referrals View source Failure to consolidate and disseminate prisoner concerns in daily briefing sheets View source Insufficient overnight staffing to take prisoners in mental health crisis to hospital View source Failure to provide necessary clinical knowledge for overnight mental health risk assessment View source Failure of the ACCT process to protect non-suicidal prisoners in acute mental health crisis View source Lack of a process to expedite face-to-face parole hearings for eligible IPP prisoners View source See 8 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
Haydar Jefferies · 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
Haydar Jefferies was detained at HMP Coldingley and developed severe depression and psychosis before self-ligaturing in his cell on 1 March 2023; he was resuscitated but died at hospital on 5 March 2023 from hypoxic brain injury and pneumonia. The principal concerns included failures to record and share risk-relevant information, refer him promptly to mental health services, provide an adequate mental health assessment and obtain appropriate clinical care and supervision during his acute deterioration.
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 medication for acute mental health symptoms overnight
Wider context from the report “6. Outside of weekday office hours there is no clinical mental health provision. Overnight staffing levels are such that it is difficult for prisoners in mental health crisis to be taken to hospital. As a result:
a.) custodial staff take decisions about how to keep prisoners safe overnight without the necessary clinical knowledge to assess the risks presented by their mental health conditions.
b.) it is not possible for medication to be obtained to alleviate any acute mental health symptoms between 6.30 pm and 7am the following morning .
” 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 Unavailability of clinical mental health provision outside weekday office hours
Wider context from the report “6. Outside of weekday office hours there is no clinical mental health provision . Overnight staffing levels are such that it is difficult for prisoners in mental health crisis to be taken to hospital. As a result:
a.) custodial staff take decisions about how to keep prisoners safe overnight without the necessary clinical knowledge to assess the risks presented by their mental health conditions.
b.) it is not possible for medication to be obtained to alleviate any acute mental health symptoms between 6.30 pm and 7am the following morning.
” 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 prisoner welfare information provided in telephone calls
Wider context from the report “1. There is no system in place to ensure that information provided in telephone calls in relation to a prisoner’s welfare is recorded .
” 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 composite 24-hour information document for clinicians reviewing CSU prisoners
Wider context from the report “3. There is no composite document for clinicians to review to see all relevant information recorded by custodial staff about a CSU prisoner for the proceeding 24 hour period .
” 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 custody staff training to recognise red flags of declining mental health
Wider context from the report “5. Custody staff are not trained in mental health presentations and are unable to recognise red flag indicators of declining mental health .
” 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 verify completion of requested mental health referrals
Wider context from the report “4. There is no system in place to check that referrals to the mental health teams requested by senior members of the prison staff have in fact been made .
” 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 consolidate and disseminate prisoner concerns in daily briefing sheets
Wider context from the report “2. Matters of concern in relation to prisoners are recorded across a number of different records and there is a risk that the information is missed and not disseminated in daily briefing sheets .
” 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 overnight staffing to take prisoners in mental health crisis to hospital
Wider context from the report “6. Outside of weekday office hours there is no clinical mental health provision. Overnight staffing levels are such that it is difficult for prisoners in mental health crisis to be taken to hospital . As a result:
a.) custodial staff take decisions about how to keep prisoners safe overnight without the necessary clinical knowledge to assess the risks presented by their mental health conditions.
b.) it is not possible for medication to be obtained to alleviate any acute mental health symptoms between 6.30 pm and 7am the following morning.
” 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 necessary clinical knowledge for overnight mental health risk assessment
Wider context from the report “6. Outside of weekday office hours there is no clinical mental health provision. Overnight staffing levels are such that it is difficult for prisoners in mental health crisis to be taken to hospital. As a result:
a.) custodial staff take decisions about how to keep prisoners safe overnight without the necessary clinical knowledge to assess the risks presented by their mental health conditions .
b.) it is not possible for medication to be obtained to alleviate any acute mental health symptoms between 6.30 pm and 7am the following morning.
” 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 the ACCT process to protect non-suicidal prisoners in acute mental health crisis
Wider context from the report “7. The ACCT process is not designed nor effective to protect prisoners in acute mental health crisis who do not appear to be suicidal .
” 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 process to expedite face-to-face parole hearings for eligible IPP prisoners
Wider context from the report “8. Imprisonment under an IPP is a recognised suicide risk. The delay in dealing with the IPP parole hearing exacerbated the risk. There is currently no process in place to expedite face to face parole hearings for IPP prisoners when allegations leading to their recall have been withdrawn and no criminal action is being considered .
” Open source report
4 Dec 2024 Kayleigh Ann MELHUISH · Prevention of Future Deaths report Avon
View report summary
Concerns raised 5 Failure by healthcare staff to check and update ACCT care plan support actions during reviews View source Ligature point where the Residential Unit 3 privacy screen meets the wall View source Failure to complete or review ACCT care plans and support actions at every review View source Lack of understanding of when and how constant supervision can be used View source Lack of mandatory neurodiversity training for prison staff 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
Kayleigh Ann MELHUISH · 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
Kayleigh Ann Melhuish died on 7 July 2022 after being found hanging in her cell at HMP Eastwood Park and later taken to hospital. The report identifies concerns about staff understanding of neurodiversity, completion of ACCT care plans and support actions, use of constant supervision, and a ligature point in Residential Unit 3. The inquest concluded that suspension by a ligature contributed to the death by neglect.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure by healthcare staff to check and update ACCT care plan support actions during reviews
Wider context from the report “2. Healthcare (AWP and PPG): training issues arose in relation to, when attending ACCT reviews that they check the care plan with support actions part of the document is reviewed and if necessary updated ; it was suggested that consideration could be made to making changes to the system-one database to check this step has been taken.
” 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 Ligature point where the Residential Unit 3 privacy screen meets the wall
Wider context from the report “3. To HMP Eastwood: the ligature point in Residential Unit 3 where the privacy screen meets the wall .
” 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 complete or review ACCT care plans and support actions at every review
Wider context from the report “1. To HMP Eastwood Park and The Ministry of Justice - training issues in relation to the following areas for new and existing staff:
a. Neurodiversity, I am told 75% of women in prison have mental health or neurodiverse issues, this training is not mandatory;
b. ACCT, there was little understanding of the requirement to complete or review the care plan and support actions at every ACCT review not just the planned reviews ;
c. Little or no understanding of when constant supervision can be used and how is it used;
” 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 understanding of when and how constant supervision can be used
Wider context from the report “1. To HMP Eastwood Park and The Ministry of Justice - training issues in relation to the following areas for new and existing staff:
a. Neurodiversity, I am told 75% of women in prison have mental health or neurodiverse issues, this training is not mandatory;
b. ACCT, there was little understanding of the requirement to complete or review the care plan and support actions at every ACCT review not just the planned reviews;
c. Little or no understanding of when constant supervision can be used and how is it used ;
” 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 neurodiversity training for prison staff
Wider context from the report “1. To HMP Eastwood Park and The Ministry of Justice - training issues in relation to the following areas for new and existing staff:
a. Neurodiversity, I am told 75% of women in prison have mental health or neurodiverse issues, this training is not mandatory ;
b. ACCT, there was little understanding of the requirement to complete or review the care plan and support actions at every ACCT review not just the planned reviews;
c. Little or no understanding of when constant supervision can be used and how is it used;
” Open source report
3 Dec 2024 Paul Martin GOBELL · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 4 Lack of arrangements for welfare checks when the First Night Interview cannot take place View source Failure to obtain Probation input for Open Conditions Suitability Assessments View source Failure to communicate changes in cell sharing risk promptly to prisoners View source Failure to report prisoner disclosures to the Offender Management Unit 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
Paul Martin GOBELL · 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
The supplied text does not describe the circumstances or date of Paul Martin Gobell’s death. It raises concerns about the absence of a welfare check and ACCT after a First Night Interview was missed, communication about cell-sharing risk, and the lack of Probation input into an assessment of his suitability for open conditions.
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 arrangements for welfare checks when the First Night Interview cannot take place
Wider context from the report “1. Paul Gobell was serving a life sentence for rape. He had served fifteen years in a closed prison, most recently at HMP Prison, Whatton. In August 2021, he was deemed by the Parole Board to be suitable for a move to open conditions and was therefore transferred to HM Prison Hollesley Bay on 20/10/21. He was there for just two and a half weeks. Within a few hours of his return to HM Prison, Whatton on 04/11/21 he was subject to a Control & Restraint incident. His behaviour at this time was reported to be refractory and aggressive. During the incident he received a soft tissue injury which necessitated a trip to the A&E department at the local hospital. As a result, the usual First Night Interview did not take place that evening, nor on the following day. As a result there was no welfare check and no ACCT was opened. There is no national or local policy in place stating what arrangements should be made to carry out a welfare check when, for operational reasons, the First Night Interview cannot take place.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain Probation input for Open Conditions Suitability Assessments
Wider context from the report “3. Whilst at HM Prison, Hollesley Bay, Paul Gobell rang the Probation Officer (who had dealt with his Parole Board hearing in August 2021) and told her that he felt he was a poor fit in open conditions, that the environment there was hostile and unpleasant and that he had let slip to another prisoner that he was serving a term of imprisonment for offences of a sexual nature. The Probation Officer concerned did not see fit to report these disclosures to the Offender Management Unit. An Open Conditions Suitability Assessment ('OCSA') was subsequently held at HM Prison, Hollesley Bay on 02/11/24, after Mr. Gobell spoke to an Orderly Officer and asked to be returned to HM Prison, Whatton. Despite the multi-disciplinary nature of the OCSA, no input was obtained or requested from Probation staff at HM Prison, Hollesley Bay or elsewhere. Had the relevant Probation staff been involved this would have better informed the OCSA and steps could have been taken to offer Mr Gobell additional support, designed to encourage him to remain in the open conditions of a 'D' category prison rather than taking the regressive step of being returned to closed conditions. Consideration should be given to imposing a requirement that the input of Probation (both from the Offender Management Unit and outside) is obtained whenever a OCSA is undertaken.
” 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 changes in cell sharing risk promptly to prisoners
Wider context from the report “2. Paul Gobell was assessed as being suitable to share a cell in June 2021, having previously been considered high risk. He was not informed off this change until immediately prior to the C&R incident on 04/11/21 and had never had to share a cell before. The Cell Sharing Risk Assessment carried out by Healthcare and Reception staff upon his return to HM Prison, Whatton on 04/11/21 deemed him to be a standard risk. He felt that he should have been designated as high risk. He was concerned for the safety of whoever he might be required to share a cell with, due to the fact that he (Gobell) suffered from paraomnia. Despite protesting to staff, he was told that he would have to share and it was this that sparked the incident leading to the use of control and restraint techniques. Had he been pre-warned of the change to his cell sharing status this incident would not have happened. Consideration should be given to ensuring that any such change of cell sharing risk is communicated promptly to the prisoner concerned.
” 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 report prisoner disclosures to the Offender Management Unit
Wider context from the report “3. Whilst at HM Prison, Hollesley Bay, Paul Gobell rang the Probation Officer (who had dealt with his Parole Board hearing in August 2021) and told her that he felt he was a poor fit in open conditions, that the environment there was hostile and unpleasant and that he had let slip to another prisoner that he was serving a term of imprisonment for offences of a sexual nature. The Probation Officer concerned did not see fit to report these disclosures to the Offender Management Unit. An Open Conditions Suitability Assessment ('OCSA') was subsequently held at HM Prison, Hollesley Bay on 02/11/24, after Mr. Gobell spoke to an Orderly Officer and asked to be returned to HM Prison, Whatton. Despite the multi-disciplinary nature of the OCSA, no input was obtained or requested from Probation staff at HM Prison, Hollesley Bay or elsewhere. Had the relevant Probation staff been involved this would have better informed the OCSA and steps could have been taken to offer Mr Gobell additional support, designed to encourage him to remain in the open conditions of a 'D' category prison rather than taking the regressive step of being returned to closed conditions. Consideration should be given to imposing a requirement that the input of Probation (both from the Offender Management Unit and outside) is obtained whenever a OCSA is undertaken.
” Open source report
Concerns raised 2 Lack of available suitable Approved Premises accommodation for prisoners released from custody View source Lack of local-authority accommodation to prevent homelessness among prisoners released from custody 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
Barrie Forster · 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
Barrie Forster was assaulted on 20 November 2020 by a person who had been released from custody two days earlier, and the inquest recorded multi-organ failure following acute upper gastrointestinal haemorrhage and craniofacial trauma. The report identified failures to assess the risk posed to Barrie and the suitability of the address where the perpetrator intended to live. It also raised a broader concern about inadequate accommodation for people released from custody, resulting in homelessness or placement in unsuitable premises.
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 available suitable Approved Premises accommodation for prisoners released from custody
Wider context from the report “There is a lack of accommodation available to the Probation Service in which prisoners released from custody may properly be placed. This includes both Approved Premises (which I understand to be the responsibility of the MoJ) and more generally through the local authority to avoid homelessness. As a consequence, some prisoners are released and become effectively homeless (with increased difficulties in supervision) while others are accommodated at unsuitable premises, as happened in this instance.
” 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-authority accommodation to prevent homelessness among prisoners released from custody
Wider context from the report “There is a lack of accommodation available to the Probation Service in which prisoners released from custody may properly be placed. This includes both Approved Premises (which I understand to be the responsibility of the MoJ) and more generally through the local authority to avoid homelessness . As a consequence, some prisoners are released and become effectively homeless (with increased difficulties in supervision) while others are accommodated at unsuitable premises, as happened in this instance.
” Open source report
31 Oct 2024 Wayne Anthony BAYLEY · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 1 Failure to share learning and improvements in practice across prisons nationally 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
Wayne Anthony BAYLEY · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Wayne Anthony Bayley died in HMP Pentonville approximately ten hours after a restraint. His death involved acute chest syndrome, hypoxia, chronic sickle cell lung disease and sickle cell disease; the principal concern was that learning and improvements relating to the care of prisoners with underlying health conditions may not have been shared nationally.
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 learning and improvements in practice across prisons nationally
Wider context from the report “However, I am not at all clear that this work has been replicated nationally . Whilst PPG provides healthcare in 57 prisons, I understand that there are over double that number in England & Wales. I did hear evidence of the work of University College London Hospital in setting up an innovative outreach pilot. Nevertheless, my concern remains that learning and improvements in practice may not have been shared across the country .
” Open source report
Concerns raised 6 Inadequate first and earliest emergency response by prison officer staff View source Failure of lone prison officers to enter cells during emergencies View source Inadequate guidance and training for prison officers on emergency cell entry View source Failure to provide refresher first aid and CPR training to prison officers View source Failure to maintain unobscured cell observation panels for routine visual welfare checks View source Failure to provide prison officers with foundation first aid and CPR training 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.
×
AI-generated summary
Stephen Anthony SLEAFORD · 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
Stephen Anthony Sleaford, a prisoner at Gartree Prison, was found with a ligature around his neck in his cell on 27 October 2022 and was pronounced dead at 08:01. The concerns included inadequate first-aid and CPR training for prison officers, gaps in the earliest emergency response, obscured cell observation panels, and unclear guidance about entering cells during emergencies.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Inadequate first and earliest emergency response by prison officer staff
Wider context from the report “3) Following the conclusion of the Inquest, I remain concerned that prison officer staff have an unrealistic expectation that prison healthcare staff will be willing and able to react timeously to any emergency unfolding , meaning there are obvious and crucial gaps in the extent and adequacy of the first/earliest response to any emergency unfolding .
” 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 lone prison officers to enter cells during emergencies
Wider context from the report “5) I am concerned that there is no, or no adequate, clear understanding by, and/or clear guidance and training provided to, prison officers around when they should enter a prison cell when it is reasonably believed that a prisoner requires immediate care or assistance due to an emergency, medical or otherwise. Evidence indicated that a ‘dynamic risk assessment’ could be undertaken by any officer who was acting/operating alone, when considering necessary and immediate entry into a cell, whereas the majority of evidence aired was that officers would ‘never’ enter a prison cell when working alone, due to fears for own safety .
” 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 guidance and training for prison officers on emergency cell entry
Wider context from the report “5) I am concerned that there is no, or no adequate, clear understanding by, and/or clear guidance and training provided to, prison officers around when they should enter a prison cell when it is reasonably believed that a prisoner requires immediate care or assistance due to an emergency, medical or otherwise. Evidence indicated that a ‘dynamic risk assessment’ could be undertaken by any officer who was acting/operating alone, when considering necessary and immediate entry into a cell, whereas the majority of evidence aired was that officers would ‘never’ enter a prison cell when working alone, due to fears for own safety.
” 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 refresher first aid and CPR training to prison officers
Wider context from the report “1) Evidence was heard that the majority of those prison officers who had commenced in their roles prior to 2018 had no first aid/basic life-saving skills and no ability/training in undertaking cardiopulmonary resuscitation (‘CPR’). Officers who had completed prison officer training between approximately April 2018 and April 2024 did have first aid training, but there had been no refresher training, subsequently, for that cohort .
2) Evidence was heard that after April 2024, basic first aid training (including CPR training) has been omitted from the foundation training programme for those training to be prison officers, meaning that NO new prison officers will have first aid/related training. I am gravely concerned that this situation (i.e. a lack of such training provided as foundation training), if it prevails, will probably lead to future deaths 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 maintain unobscured cell observation panels for routine visual welfare checks
Wider context from the report “4) The evidence revealed that despite clear instruction to officers, by way of Notices to Staff from senior management at the prison, to the effect that obscuring cell door observation panels on the inside by prisoners was not permitted practice and was to be challenged and remedied, routine practice by prison officers meant observation panels were permitted to be obscured, without challenge or sanction . This means that a situation prevailed whereby prison officers were unable to routinely see into all cells to check prisoner welfare , but were/are reliant on, and accepted, a verbal response only , which is and remains a significant 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 Failure to provide prison officers with foundation first aid and CPR training
Wider context from the report “1) Evidence was heard that the majority of those prison officers who had commenced in their roles prior to 2018 had no first aid/basic life-saving skills and no ability/training in undertaking cardiopulmonary resuscitation (‘CPR’) . Officers who had completed prison officer training between approximately April 2018 and April 2024 did have first aid training, but there had been no refresher training, subsequently, for that cohort.
2) Evidence was heard that after April 2024, basic first aid training (including CPR training) has been omitted from the foundation training programme for those training to be prison officers , meaning that NO new prison officers will have first aid/related training. I am gravely concerned that this situation (i.e. a lack of such training provided as foundation training ), if it prevails, will probably lead to future deaths in prison custody.
” Open source report
9 Sep 2024 Ian William Deavall · Prevention of Future Deaths report Greater Manchester West
View report summary
Concerns raised 2 Risk of non-VP prisoners victimising VP prisoners View source Failure of emergency cell bells to remain operable and alert prison staff 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
Ian William Deavall · 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
Ian William Deavall, who had ischaemic heart disease and hypotension, suffered a cardiac arrest in his cell at HMP Forest Bank on 24 January 2023. The emergency cell bell was deactivated by another prisoner, cancelling the alert in the wing office and removing the only indication of the exact cell, so staff became aware of the emergency more by accident than design. The report identifies an ongoing risk because emergency cell bells can still be readily deactivated by other prisoners and no fail-safe measures are currently proposed.
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 Risk of non-VP prisoners victimising VP prisoners
Wider context from the report “(1) The response to a medical emergency will generally be time critical.
(2) The risk that non-VP prisoners will victimise VP prisoners is a recognised one.
(3) That prison staff became aware of the medical emergency in the Deceased’s case was more by accident than design (depending as it did on the caprice of Prisoner A).
There remains a risk that future deaths could occur as it remains the case that emergency cell bells at HMP Forest Bank can be deactivated readily and altogether by other prisoners and no action to implement fail-safe measures is currently proposed.
” 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 emergency cell bells to remain operable and alert prison staff
Wider context from the report “(1) The response to a medical emergency will generally be time critical.
(2) The risk that non-VP prisoners will victimise VP prisoners is a recognised one.
(3) That prison staff became aware of the medical emergency in the Deceased’s case was more by accident than design (depending as it did on the caprice of Prisoner A).
There remains a risk that future deaths could occur as it remains the case that emergency cell bells at HMP Forest Bank can be deactivated readily and altogether by other prisoners and no action to implement fail-safe measures is currently proposed .
” Open source report
Concerns raised 1 Failure to share and discuss investigation findings and recommendations with relevant prison and healthcare staff 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
Craig Steadman · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Craig Steadman was in custody at HMP Winchester and had diabetes, a mental health history, and previous self-harming incidents. He was found suspended by a ligature in his cell after a further self-harm incident, and CPR was unsuccessful. The principal concern was that findings and recommendations from investigations into his death were not shared with staff directly involved in his care, limiting the dissemination and implementation of learning.
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 and discuss investigation findings and recommendations with relevant prison and healthcare staff
Wider context from the report “There were several investigations into Craig Steadman’s death including a post incident review by HMP Winchester, the PPO,and the prison healthcare provider.
Various recommendations flowed from the above.
However upon questioning of various members of staff called to give evidence at the Inquest it became clear that several of them were not aware of the findings of the investigations nor the recommendations . The reports had not been shared with staff directly involved with Craig during his recent time in custody .
It is not possible for learning to be fully disseminated and acted upon if there is no process for sharing the findings of those organisations tasked with investigating deaths in custody and discussing these with the relevant Prison/Healthcare staff .
” Open source report
8 Aug 2024 Sean Martin DAVIES · Prevention of Future Deaths report Mid Kent and Medway
View report summary
Concerns raised 4 Lack of required operational support group officer training in fire regulations and handovers View source Failure of operational support group officers to act in accordance with training View source Failure to conduct prisoner welfare checks in line with national guidance and local policies View source Potential suicide and self-harm risk among prisoners subject to IPP sentences 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
Sean Martin DAVIES · 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
Sean Martin Davies, who was serving an indeterminate sentence for public protection at HMP Swaleside, died by suspension in his cell on 25 February 2023. He had expressed hopelessness and left a note linking his death to the IPP sentence. Concerns included risk assessment and management for prisoners subject to IPP sentences, welfare checks not being conducted in line with guidance or policy, and shortcomings in staff training and handovers.
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 required operational support group officer training in fire regulations and handovers
Wider context from the report “(3) One operational support group officer had not received training in relation to fire regulations or handovers , another did not act in accordance with the training
” 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 operational support group officers to act in accordance with training
Wider context from the report “(3) One operational support group officer had not received training in relation to fire regulations or handovers, another did not act in accordance with the training
” 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 conduct prisoner welfare checks in line with national guidance and local policies
Wider context from the report “(2) It was clear from CCTV evidence that prison officers and operational support group officers were not conducting roll call welfare checks and other welfare checks in line with national guidance or local policies
” 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 Potential suicide and self-harm risk among prisoners subject to IPP sentences
Wider context from the report “(1) There are currently 55 prisoners at HMP Swaleside subject to IPP sentences. It has been recognised by the Prison and Probation Ombudsman that an IPP sentence should be regarded as a potential risk factor for suicide and self harm (learning lessons bulletin September 2023). In the clinical review following the death of Mr. Davies a recommendation was made that the Governor and Head of Healthcare ensure that a risk formulation was completed for all prisoners subject to IPP sentences, that it was regularly reviewed and updated including where there has been an event that may increase a person's risk of suicide and self harm. Such formulation should be made readily available for all staff to refer and be stored within the prison and medical records. I understood from representations made on behalf of the Ministry of Justice that a 'national strategy' was intended for IPP prisoners. At the end of the inquest I gave the Governor and Head of Healthcare some time to notify me of the steps that had been taken in relation to the recommendation of the clinical review and any interim measures in respect of the 'national strategy'. Whilst I have been provided with the changes in practice that have been put in place by Head of Healthcare, I have been asked by the safer custody team at HMP Swaleside to issue a Regulation 28 report so that a considered response can be provided in relation to this matter and the concerns below
” Open source report
1 Aug 2024 Leah Shannon Croucher · Prevention of Future Deaths report Milton Keynes
View report summary
Concerns raised 2 Failure to adequately monitor sex offenders in the community View source Failure to share information between agencies supervising sex offenders View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Leah Shannon Croucher · 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
Leah Shannon Croucher left home to walk to work on 15 February 2019 but did not arrive, and her body was found in a Milton Keynes house in October 2022. The inquest concluded that she was unlawfully killed. The report raises concerns about the supervision of a known repeat sex offender and information sharing between the police and probation service.
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 adequately monitor sex offenders in the community
Wider context from the report “Leah Croucher was unlawfully killed by a man who was subject to supervision by the probation service and the police. Despite that supervision he was in breach of the terms of his probation and was able to kill Leah when it was known that he was a predator and danger to females. There should be a fundamental review of the process for monitoring sex offenders in the community and the sharing of information between all agencies particularly the police and probation service to ensure that a similar death can be prevented.
” 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 share information between agencies supervising sex offenders
Wider context from the report “Leah Croucher was unlawfully killed by a man who was subject to supervision by the probation service and the police. Despite that supervision he was in breach of the terms of his probation and was able to kill Leah when it was known that he was a predator and danger to females. There should be a fundamental review of the process for monitoring sex offenders in the community and the sharing of information between all agencies particularly the police and probation service to ensure that a similar death can be prevented.
” Open source report
×
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 improving ViSOR delivery as the region’s primary multi-agency information-sharing system.
Verbatim wording from the response “We will work with the national Assessment and Management of Sexual Offending (AMSO) Team within HMPPS to share the findings from our review, to support any learning on a national basis, disseminating any outcomes or proposed practice changes which arise from it. This will include continued improvement of the effective and efficient delivery of ViSOR as the primary means of multi-agency information sharing in the region. National projects are ensuring that all areas are working to establish the use of ViSOR as a business-as-usual system in sentence management. Over the last 3 years these projects have seen a steady rise in the number of HMPPS staff with access to ViSOR, rising from less than 300 to more than 3500. These numbers continue to increase by approximately” Source location Response from HMPPS - Probation Service South Central
Open published response
×
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 Review information-sharing practice at pre-sentence report stage and throughout order or licence management, concluding by 31 March 2025.
Verbatim wording from the response “Within the Probation Service, we will focus our review on information sharing practice at the pre-sentence report stage and throughout the management of an order or licence, building on the actions set out in the internal Serious Further Offence (SFO) review. The Pathfinder to Improved Pre-Sentence Advice (PIPA) project is piloting in the South Central Probation Region. This project aims to improve the quality of Pre-Sentence advice to the Judiciary. This includes reviewing cases further in advance of upcoming hearings. This gives staff more time to gather information from other agencies and consider the implications for risk and the suitability of various sentencing options. We will specifically consider how this is supporting the preparation of reports on registered sex offenders in light of this case.” Source location Response from HMPPS - Probation Service South Central
Open published response
×
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 capacity to train 40 staff monthly in ViSOR.
Verbatim wording from the response “300 a month and the intention is that more than 12,000 HMPPS members of staff will have access to ViSOR by the time it is replaced by a more dynamic and agile system (MAPPS) in 2026. In South Central ViSOR usage has been increased steadily and now 35% of in scope staff have access to the database. We will continue to provide capacity to train 40 staff a month and pending vetting being timely will deliver full access in a year.” Source location Response from HMPPS - Probation Service South Central
Open published response
×
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 Oversee a review of multi-agency processes for monitoring sexual offenders and exchanging police and probation information.
Verbatim wording from the response “The Chair of the SMB has accepted that the Board should oversee a piece of work to review the effectiveness of the multi-agency processes for monitoring sex offenders and for information exchange between police and probation. This will build on the extensive learning which came from the MAPPA Serious Case Review (SCR) and associated action plan, which is due to be implemented in full by August 2025.” Source location Response from HMPPS - Probation Service South Central
Open published response
×
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 Consider how the PIPA project supports preparation of reports on registered sex offenders.
Verbatim wording from the response “Within the Probation Service, we will focus our review on information sharing practice at the pre-sentence report stage and throughout the management of an order or licence, building on the actions set out in the internal Serious Further Offence (SFO) review. The Pathfinder to Improved Pre-Sentence Advice (PIPA) project is piloting in the South Central Probation Region. This project aims to improve the quality of Pre-Sentence advice to the Judiciary. This includes reviewing cases further in advance of upcoming hearings. This gives staff more time to gather information from other agencies and consider the implications for risk and the suitability of various sentencing options. We will specifically consider how this is supporting the preparation of reports on registered sex offenders in light of this case.” Source location Response from HMPPS - Probation Service South Central
Open published response
×
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 full ViSOR access to in-scope South Central staff within a year, subject to timely vetting.
Verbatim wording from the response “300 a month and the intention is that more than 12,000 HMPPS members of staff will have access to ViSOR by the time it is replaced by a more dynamic and agile system (MAPPS) in 2026. In South Central ViSOR usage has been increased steadily and now 35% of in scope staff have access to the database. We will continue to provide capacity to train 40 staff a month and pending vetting being timely will deliver full access in a year.” Source location Response from HMPPS - Probation Service South Central
Open published response
×
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 Introduce policy frameworks for pre-sentence reports, home visits and MAPPA level 1 case management.
Verbatim wording from the response “Probation Service, when the former Community Rehabilitation Companies were dissolved in 2021, and attendant changes to organisational structure, policy and practice. Since then, the Probation Service has taken steps to strengthen our management of those who have committed sexual offences. We have streamlined risk assessments for such offenders and introduced a new national learning programme for all experienced probation officers to improve their knowledge and skills in this vital area of public protection work. We have also introduced new policy frameworks covering the preparation of pre-sentence reports, requirements to undertake home visits and expectations when it comes to cases managed at level 1 under MAPPA. ████████ was managed at MAPPA level 1 at the time Leah Croucher was killed).” Source location Response from HMPPS - Probation Service South Central
Open published response
1 Aug 2024 Matthew Paul Braben · Prevention of Future Deaths report West London
View report summary
Concerns raised 6 Prisoners being kept in their cells for up to 23 hours a day View source Failure to ensure the ACCT post-closure process is followed after moves to another location View source Gym instructor training arrangements creating significant disincentives for staff to train View source Insufficient training of staff in the ACCT process View source Failure to recognise the birth of a child as a specific mental-health risk factor View source Shortage of gym instructors 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.
×
AI-generated summary
Matthew Paul Braben · 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 Paul Braben died by asphyxia at HMP Wormwood Scrubs on 16 August 2021 after being found in his cell with his neck, wrists and ankles tied. The report identified concerns including failures to identify and respond to suicide risk, inadequate communication and record-keeping, failures relating to ACCT processes, and the impact of prisoners being held in their cells for up to 23 hours a day.
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 Prisoners being kept in their cells for up to 23 hours a day
Wider context from the report “4. Prisoners being kept in their cells for up to 23 hours a day , with a negative effect on their mental health .
” 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 the ACCT post-closure process is followed after moves to another location
Wider context from the report “2. The robustness of the process for ensuring that the ACCT post-closure process is followed , particularly following a move to another location .
” 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 Gym instructor training arrangements creating significant disincentives for staff to train
Wider context from the report “5. The manner of training of gym instructors which entails potential trainees having to attend training at a distant location for significant period of times rather than locally as well as the length of the course , both of which serve as significant disincentives for staff to be trained as gym instructors . The shortage of gym instructors leads directly to more prisoners being kept in their cells for up to 23 hours a day, with a negative effect on their mental health.
” 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 training of staff in the ACCT process
Wider context from the report “3. Training of staff in the ACCT process .
” 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 the birth of a child as a specific mental-health risk factor
Wider context from the report “1. The birth of a child is not recognised as a specific risk factor in PSI 64/2011 which means that staff may under-estimate its significance on mental health .
” 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 Shortage of gym instructors
Wider context from the report “5. The manner of training of gym instructors which entails potential trainees having to attend training at a distant location for significant period of times rather than locally as well as the length of the course, both of which serve as significant disincentives for staff to be trained as gym instructors. The shortage of gym instructors leads directly to more prisoners being kept in their cells for up to 23 hours a day , with a negative effect on their mental health.
” Open source report
26 Jul 2024 Zara Natasha Aleena · Prevention of Future Deaths report East London
View report summary
Concerns raised 25 Failure to provide prison risk intelligence to Integrated Offender Management meetings View source Threshold for reflective practice set too high View source Unclear understanding of when to request emergency recall View source Lack of mandatory and refreshed risk assessment training View source Lack of supervision for prison offender managers View source Failure to examine local intelligence and Computer Aided Dispatch systems in sufficient detail View source Lack of systems to support staff supervising key decisions View source Lack of alerts for handover from prison to community offender managers View source Lack of checks on sharing up-to-date and accurate risk assessments View source Failure of prison offender managers to implement sentence plans and facilitate rehabilitation View source Lack of focused risk assessment training for prison offender managers View source Lack of rigour, detail and independence in MPS investigations View source Unclear and incomplete sharing of risk information between probation and the MPS View source Failure to conduct timely risk assessments with complementary risk management plans View source Societal acceptance of unreported following behaviour View source Unclear CCTV operator training on identifying sexual predators and stalking behaviour View source Lack of assurance and refresher training for CCTV operators View source Failure to holistically assess indicators of serious harm View source Failure of alert systems to highlight restraining orders View source Lack of reporting guidance and training for business owners on sexualised or predatory behaviour View source OASYS risk assessment tool failing to support extraction and analysis of key risk areas View source Understaffing of probation delivery units View source Failure to probe information relevant to risk View source Obstacles inhibiting increases in assessed risk levels View source Failure of prison offender managers to gather and share evidence relevant to risk formulation View source See 22 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
Zara Natasha Aleena · 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
Zara Natasha Aleena died at the Royal London Hospital on 26 June 2022 after sustaining a severe traumatic brain injury during an unprovoked attack while walking home in Ilford. The report identifies concerns about understaffing, risk assessment, information sharing, supervision, recall procedures and coordination across the Probation Service, police and other agencies, as well as concerns about training and reporting of predatory behaviour.
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 prison risk intelligence to Integrated Offender Management meetings
Wider context from the report “(15)The Integrated Offender Management meetings did not receive the necessary intelligence from the prison setting . There was no system in place to ensure that either the prison offender manager was invited to attend, or that the prison offender manager was asked to provide written information around risk incidents .
” 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 Threshold for reflective practice set too high
Wider context from the report “(18)There were clearly learning points for the police constables, police sergeants and the local intelligence team. The MPS rejected the DPS recommendation for reflective learning, “as there was no failing in performance or conduct”. It is of concern that the threshold for reflective practice is set too high .
” 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 Unclear understanding of when to request emergency recall
Wider context from the report “(10) The evidence revealed a difference of opinion and understanding around when an emergency recall should be requested . A senior probation officer and probation services officer erroneously believed that an emergency recall could only be requested out of hours .
” 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 and refreshed risk assessment training
Wider context from the report “(4) Risk assessment training is not part of the mandatory training framework within the probation service. Risk assessment training is not refreshed .
” 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 supervision for prison offender managers
Wider context from the report “(12)There was no evidence that the prison offender manager from February 2021 to October 2021 paid any attention to the sentence plan in place for the offender. They did not attempt to facilitate any rehabilitative interventions. There was no evidence of supervision for the prison offender manager .
” 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 examine local intelligence and Computer Aided Dispatch systems in sufficient detail
Wider context from the report “(17)The Fast Time Review did not probe into sufficient detail into the systems of the local intelligence team and the Computer Aided Dispatch process . A more detailed, independent review should have been carried out.
” 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 systems to support staff supervising key decisions
Wider context from the report “(2) There were no systems in place devised to assist the staff working in these stretched circumstances , such as easy reference checklists for supervising key decisions .
” 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 alerts for handover from prison to community offender managers
Wider context from the report “(13)There was no system in place to alert the prison offender manager to handover an offender to the community offender manager when a period of sentence ended and where the offender remained in prison, on remand.
” 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 checks on sharing up-to-date and accurate risk assessments
Wider context from the report “(5) There were no checks to ensure the provision of up to date and accurate risk assessments to partner agencies (such as the housing team).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure of prison offender managers to implement sentence plans and facilitate rehabilitation
Wider context from the report “(12)There was no evidence that the prison offender manager from February 2021 to October 2021 paid any attention to the sentence plan in place for the offender . They did not attempt to facilitate any rehabilitative interventions . There was no evidence of supervision for the prison offender manager.
” 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 focused risk assessment training for prison offender managers
Wider context from the report “(11) The role of the prison offender manager is to gather evidence to assist with the formulation of risk. Prison offender managers do not however receive focussed risk assessment training . Neither of the prison offender managers in this case gathered evidence to assist with the formulation of risk. There were multiple intelligence logs and records that should have been obtained by them. The logs included findings of possession of weapons, drug taking, threats to harm others and a sustained assault on a servery worker using an improvised weapon. This information was not gathered and shared appropriately.
” 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 rigour, detail and independence in MPS investigations
Wider context from the report “(16)I am concerned about the lack of rigour, detail and independence of the MPS investigation into this case. The unit involved in this case was the East Area BCU. An independent, rapid investigation (Fast Time Review) was carried out by the Directorate of Professional Standards. Despite the very limited time to complete the review, the DPS officer reached clear and valuable findings. The findings of the DPS investigator were however rejected by more senior officers within the MPS. The officers who rejected the findings were not independent and all worked within the East Area BCU. This lack of independence is 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 Unclear and incomplete sharing of risk information between probation and the MPS
Wider context from the report “(14)The system in place for sharing risk information between the probation service and the MPS was unclear . Only very limited intelligence was shared with the MPS . There was no explanation as to why that information was shared, when more concerning risk related information was not shared .
” 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 conduct timely risk assessments with complementary risk management plans
Wider context from the report “(3) The understanding around risk assessment was poor , at all levels of staffing. The practical application of risk assessment was poor at all levels of staffing. Risk was not assessed at appropriate times , and the assessment of risk was not accompanied by a complementary risk management plan . Risk management plans were once prepared before risk was fully assessed (as occurred with the setting of licence conditions). One practitioner was advised to set a risk level to match other completed documents (without analysis of risk itself). Practitioners did not holistically assess risk and take account of potential indicators of serious harm, to include use of weapons; attitudes supportive of violence; callousness and high increased frequency of lower-level 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 Societal acceptance of unreported following behaviour
Wider context from the report “(21) At least two other members of the public were followed by the offender before he attacked Zara Aleena. The members of the public appear to have seen the offender and appear to be aware that he was following them. This was not brought to the attention of the emergency services. I am concerned that there is a societal acceptance that such conduct does not need to be reported .
” 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 Unclear CCTV operator training on identifying sexual predators and stalking behaviour
Wider context from the report “(19)The details of training for CCTV operators includes “training on sexual harassment”, but it is not clear whether this includes identifying sexual predators and stalking type behaviour .
” 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 assurance and refresher training for CCTV operators
Wider context from the report “(20)I am unclear from the evidence provided, whether LBR have a system for checking that training provided to CCTV operators is fully understood , or whether refresher training is provided to them .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to holistically assess indicators of serious harm
Wider context from the report “(3) The understanding around risk assessment was poor, at all levels of staffing. The practical application of risk assessment was poor at all levels of staffing. Risk was not assessed at appropriate times, and the assessment of risk was not accompanied by a complementary risk management plan. Risk management plans were once prepared before risk was fully assessed (as occurred with the setting of licence conditions). One practitioner was advised to set a risk level to match other completed documents (without analysis of risk itself). Practitioners did not holistically assess risk and take account of potential indicators of serious harm , to include use of weapons; attitudes supportive of violence; callousness and high increased frequency of lower-level 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 of alert systems to highlight restraining orders
Wider context from the report “(8) The globe system and alert systems did not work effectively in this case. A restraining order had been put in place against the offender, but this was not highlighted , as it should have been. Key staff involved in assessing and managing the offender were unaware of the restraining order .
” 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 reporting guidance and training for business owners on sexualised or predatory behaviour
Wider context from the report “(22)Business owners were aware of the offender’s concerning conduct on the night of Zara Aleena’s murder. For example, a public house had refused to provide more drinks to him. It is not clear whether business owners are encouraged to report such concerning behaviour to the authorities or whether they are offered any training to assist them and their staff to recognise sexualised or predatory behaviour .
” 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 OASYS risk assessment tool failing to support extraction and analysis of key risk areas
Wider context from the report “(7) The OASYS risk assessment tool is unwieldy and difficult to navigate . It was challenging to extract the most relevant material. The content of the OASYS assessment was so dense that the probation officers seemed to get lost in the detail and failed to pull together and formulate/analyse key risk areas . One senior probation officer stated that she would not look at the OASYS when allocating cases, because OASYS assessments were “not always accurate and up to date”. It is noted that a new risk assessment tool within the probation service is a work in progress. It is hoped that the new tool will take into account the above concerns.
” 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 Understaffing of probation delivery units
Wider context from the report “(1) The probation delivery unit responsible for the offender was understaffed at the time of relevant oversight. The staffing levels were 61% in 2022 . The staffing levels at the time of the inquest in June 2024 was 58% . The inquest heard that this is a national problem and that there are other probation delivery units that have even lower levels of staffing. The low staffing level had an impact upon quality and depth of assessments; quality of supervision of junior staff (supervision was wholly reactive); excessively high workloads for probation officers and senior probation officers; lack of cover during annual leave for probation officers and poor record keeping.
” 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 probe information relevant to risk
Wider context from the report “(6) There was a lack of professional curiosity and a lack of sufficient probing into information relevant to 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 Obstacles inhibiting increases in assessed risk levels
Wider context from the report “(9) There may be obstacles to increasing risk levels . The inquest heard that senior probation staff would have to approve increases in risk. As staffing levels are so stretched, there may be reticence of junior probation officers to trouble the senior team . The risk assessment policy also includes a statement that staff “should not use risk levels to inflate risk because of anxiety or to access resources”. It is a concern that this provision may inhibit decisions to increase 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 Failure of prison offender managers to gather and share evidence relevant to risk formulation
Wider context from the report “(11) The role of the prison offender manager is to gather evidence to assist with the formulation of risk. Prison offender managers do not however receive focussed risk assessment training. Neither of the prison offender managers in this case gathered evidence to assist with the formulation of risk . There were multiple intelligence logs and records that should have been obtained by them . The logs included findings of possession of weapons, drug taking, threats to harm others and a sustained assault on a servery worker using an improvised weapon. This information was not gathered and shared appropriately .
” Open source report
20 Jun 2024 Yasmin Louise ADAMS · Prevention of Future Deaths report Derby and Derbyshire
View report summary
Concerns raised 4 Presence of fixed shower rails creating ligature points in prisoner-accessible shower areas View source Failure of ACCT observation scheduling to avoid overly long gaps View source Failure to use appropriate cells for ACCT prisoners subject to cellular confinement View source Lack of prison staff training and awareness on personality disorder and learning disability 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
Yasmin Louise ADAMS · 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
Yasmin Louise ADAMS, who had emotionally unstable personality disorder and a history of self-harm, was found suspended and unconscious in her prison cell on 12 November 2016 and died in hospital the next day. Concerns included a 29-minute gap in observation checks, fixed shower rails presenting ligature risks, uncertainty about staff training on personality disorder and learning disability, and the use of cellular confinement for a prisoner on an ACCT.
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 Presence of fixed shower rails creating ligature points in prisoner-accessible shower areas
Wider context from the report “2. The inquest heard that HMP Foston Hall no longer has fixed shower rails in prisoner’s cell bathroom areas. It could not be confirmed to the court that other prisons across the prion estate do not have fixed shower rails in prisoner’s cell bathroom areas, or other shower areas where prisoners may be out of view of staff. Although potential ligature points are multiple within prisons, and cannot totally be eliminated, fixed shower rails present particular and clear risk of use as ligature points .
” 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 ACCT observation scheduling to avoid overly long gaps
Wider context from the report “1. Immediately prior to Yasmin’s death there had been a gap of twenty-nine minutes in her ACCT observations and at the time she was subject to four checks per hour. The relevant guidance for ACCT observation checks understandably states that the checks should not take place at set time to lessen the chances of a prisoner being able to predict when observations will occur, but the guidance does not advise avoiding overly long gaps between observation (e.g. twenty-nine minutes as in Yasmin’s case).
” 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 use appropriate cells for ACCT prisoners subject to cellular confinement
Wider context from the report “4. Yasmin was subject to cellular confinement on a residential prison wing. ‘Normal’ or ‘standard’ cells may not be best for cellular confinement, particularly for a prisoner placed on an ACCT and therefore deemed at risk and vulnerable , due to cell environment and ligature points and less ability to check and observe by prison staff . It is unclear whether appropriate cells are now used for placement of prisoners subject to ACCTS who are also subject to cellular confinement , across the prison estate.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Lack of prison staff training and awareness on personality disorder and learning disability
Wider context from the report “3. There was lack of clarity concerning what training and awareness prison staff receive on personality disorder . Yasmin was diagnosed with emotionally unstable personality disorder which could make her behaviour impulsive, and unpredictable. She had also been diagnosed with learning disability in the community which was relevant to her understanding and communication with her. I have been provided with the training course slides for Introduction to Mental Health Awareness, produced by HMPPS Learning and Development in conjunction with the National Psychology Service. I am informed that this course is delivered to prison officer staff generally. There is nothing on the slides to indicate that the course covers personality disorder or learning disability .
” Open source report
31 May 2024 Frazer Charlie Williams · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 17 Lack of guidance on transferring prisoners under healthcare-team care between establishments View source Lack of national guidance for management and operational staff on pre-transfer prisoner handover View source Lack of consultation with receiving-prison healthcare teams about care capability View source Lack of national guidance for healthcare handover to receiving prisons View source Failure to deliver the keyworker scheme in line with national guidance View source Lack of process for recording and involving prisoners’ next of kin View source Lack of NHS and joint HMPPS guidance on identifying, managing and treating self-neglect in prisons View source Delays in transferring prisoners requiring mental health hospital admission View source Lack of a national directory of healthcare facilities and provision at individual prisons View source Lack of guidance requiring consultation with prison doctors before transferring prisoners receiving medical care View source Lack of automatic flagging of missed ACCT reviews View source Lack of ACCT quality assurance between day 7 and post-closure review View source Failure to make an immediate ambulance call when a code blue or red is raised View source Failure to invite relevant individuals such as key workers to ACCT reviews View source Lack of national specification for prison healthcare units View source Failure of the email-a-prisoner system to facilitate contact after unrecognised prisoner transfers View source Camouflaging similarity between cell-door and bedsheet colours View source See 14 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
Frazer Charlie Williams · 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
Frazer Charlie Williams was found deceased on 7 March 2022 in his cell at HMP Guys Marsh, suspended by a ligature. The report identifies concerns about delays transferring prisoners requiring mental health hospital care, inadequate arrangements for managing self-neglect and healthcare handovers, shortcomings in ACCT monitoring and reviews, and other prison care and safety processes. The inquest concluded that he died by suicide in circumstances where there was inadequate assessment and monitoring of his risks of self-harm and suicide prior 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 Lack of guidance on transferring prisoners under healthcare-team care between establishments
Wider context from the report “iii. There is a lack of a national directory detailing the facilities and provision of healthcare at individual prisons across England and Wales, and associated guidance on the transfer of individuals between prison establishments when they are under the care of the healthcare teams and are not placed on medical hold . There is a lack of guidance on consultation with prison doctors where a prisoner is receiving medical care, whether that be for physical or mental health, when there is consideration by the prison to transfer the prisoner who is not placed on medical hold. Further there is a lack of consultation with the healthcare team at the proposed receiving prison to ensure they can provide the appropriate care for the person.
” 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 national guidance for management and operational staff on pre-transfer prisoner handover
Wider context from the report “vi. There is lack of national guidance for both senior management and operational prison staff in relation to the handover of a prisoner in advance of their transfer , not specific to, but especially those with complex needs, when transferring between prisons.
” 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 consultation with receiving-prison healthcare teams about care capability
Wider context from the report “iii. There is a lack of a national directory detailing the facilities and provision of healthcare at individual prisons across England and Wales, and associated guidance on the transfer of individuals between prison establishments when they are under the care of the healthcare teams and are not placed on medical hold. There is a lack of guidance on consultation with prison doctors where a prisoner is receiving medical care, whether that be for physical or mental health, when there is consideration by the prison to transfer the prisoner who is not placed on medical hold. Further there is a lack of consultation with the healthcare team at the proposed receiving prison to ensure they can provide the appropriate care for the person .
” 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 national guidance for healthcare handover to receiving prisons
Wider context from the report “iv. There is a lack of national guidance for healthcare teams working in prisons around the handover of healthcare of a prisoner to the receiving prison when they are transferred to another 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 deliver the keyworker scheme in line with national guidance
Wider context from the report “x. The keyworker scheme is not being delivered in line with national guidance at HMP Guys Marsh.
” 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 process for recording and involving prisoners’ next of kin
Wider context from the report “xiii. There is a lack of process regarding the recording of a prisoner’s next of kin and involvement of them at HMP Guys Marsh.
” 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 NHS and joint HMPPS guidance on identifying, managing and treating self-neglect in prisons
Wider context from the report “ii. There is a lack of NHS guidance, and joint guidance with HMPPS, on the identification, management, and treatment of someone with self neglect in the prison setting .
” 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 transferring prisoners requiring mental health hospital admission
Wider context from the report “i. There is inequity within the system of the treatment of a person with mental illness in the prison setting compared to an individual in the community, due to the fact that in the community a person would be placed in a hospital setting on the day they were deemed to require hospital admission, however in prison there are delays in transferring a prisoner in the same situation to hospital .
” 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 national directory of healthcare facilities and provision at individual prisons
Wider context from the report “iii. There is a lack of a national directory detailing the facilities and provision of healthcare at individual prisons across England and Wales , and associated guidance on the transfer of individuals between prison establishments when they are under the care of the healthcare teams and are not placed on medical hold. There is a lack of guidance on consultation with prison doctors where a prisoner is receiving medical care, whether that be for physical or mental health, when there is consideration by the prison to transfer the prisoner who is not placed on medical hold. Further there is a lack of consultation with the healthcare team at the proposed receiving prison to ensure they can provide the appropriate care for the person.
” 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 guidance requiring consultation with prison doctors before transferring prisoners receiving medical care
Wider context from the report “iii. There is a lack of a national directory detailing the facilities and provision of healthcare at individual prisons across England and Wales, and associated guidance on the transfer of individuals between prison establishments when they are under the care of the healthcare teams and are not placed on medical hold. There is a lack of guidance on consultation with prison doctors where a prisoner is receiving medical care , whether that be for physical or mental health, when there is consideration by the prison to transfer the prisoner who is not placed on medical hold . Further there is a lack of consultation with the healthcare team at the proposed receiving prison to ensure they can provide the appropriate care for the person.
” 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 automatic flagging of missed ACCT reviews
Wider context from the report “viii. There is lack of automatic flagging of a missed ACCT review at HMP Guys Marsh and this could also be a national problem.
” 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 ACCT quality assurance between day 7 and post-closure review
Wider context from the report “vii. The lack of ACCT quality assurance, or audit, between day 7 of the ACCT and the post closure review .
” 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 an immediate ambulance call when a code blue or red is raised
Wider context from the report “xii. PSI 03/2013 is not being followed at HMP Guys Marsh as there is no immediate call to the ambulance service when a code blue or red is raised .
” 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 invite relevant individuals such as key workers to ACCT reviews
Wider context from the report “ix. Relevant individuals, such as key workers are not being invited to attend ACCT reviews at HMP Guys Marsh in line with ACCT 6 guidance.
” 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 national specification for prison healthcare units
Wider context from the report “v. There is a lack of national specification in respect of prison healthcare units .
” 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 the email-a-prisoner system to facilitate contact after unrecognised prisoner transfers
Wider context from the report “xiv. The email a prisoner system is dependant on the person wanting to contact the prisoner knowing their location , so if the prisoner is transferred to another prison and the person contacting them is not aware, contact which can be a protective factor particularly in a prisoner’s mental health care, will not be facilitated.
” 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 Camouflaging similarity between cell-door and bedsheet colours
Wider context from the report “xi. The colour of the cell doors and bedsheets at HMP Guys Marsh, and possibly at other prisons nationally, being very similar can camouflage ligatures .
” Open source report
30 May 2024 Katie MADDEN · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 7 Failure to assess additional risks to vulnerable parents in safeguarding referrals concerning their children View source Failure to provide additional support for vulnerable recipients of a ‘Claires Law’ Domestic Violence Disclosure during child-care investigations View source Failure of the funding pathway to provide access to specialist psychological treatment View source Unavailability of Schema-based Cognitive Behavioural Therapy on the NHS View source Lack of risk assessment of vulnerable parents’ mental health and physical wellbeing at Public Law Outline notification View source Lack of independent Social Services support for vulnerable parents View source Lack of independent professional holistic case review for vulnerable parents 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
Katie MADDEN · 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
Katie Madden was declared deceased on 4 June 2023 after being found hanging, following a history of mental health conditions, domestic violence, and a toxic relationship. The report identified concerns about the lack of systems to assess and support her vulnerability during child-care proceedings and safeguarding processes, the absence of independent Social Services support, and difficulties obtaining funding for recommended psychological treatment.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to assess additional risks to vulnerable parents in safeguarding referrals concerning their children
Wider context from the report “4. Safeguarding referrals made the Multi-Agency Safeguarding Hub in respect of Kate’s children were viewed in isolation , with no system in place to assess any additional risks posed to Kate herself . There were no additional steps, or risk assessments undertaken in relation to Kate , even though she was a recipient of a ‘Claires Law’ Domestic Violence Disclosure and therefore known to be more vulnerable.
” 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 additional support for vulnerable recipients of a ‘Claires Law’ Domestic Violence Disclosure during child-care investigations
Wider context from the report “1. No evidence was seen that recipients of a ‘Claires Law’ Domestic Violence Disclosure are treated as being of greater vulnerability, or at a higher risk, when Child Services are undertaking investigations regarding the provision of children’s care, and removal of the children from a parent is being considered . It was heard in evidence that the Social Worker appointed to this case, quite properly focused on what was in the best interest of Kate’s children. There was however no formal system in place to provide additional support for Kate herself, even though she was known to be vulnerable.
” 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 the funding pathway to provide access to specialist psychological treatment
Wider context from the report “5. In 2022 it was recognised by a Clinical Psychologist that Kate could benefit from Schema-based Cognitive Behavioural Therapy, which is not routinely available on the NHS.
The psychological review had been ordered by the Family Court, and funding for this course needed to be applied for.
Applying for funding involved requests to the Legal Aid Board, Integrated Care Board (Individual Funding Request), Wellbeing Service and Social Services, none of whom provided the funding, with each suggesting contacting one of the other agencies involved .
An experienced mental health clinician with many years’ experience described the ‘whole route as very complicated’ and ‘it was difficult to find a solution for funding ’. In addition, funding was very rarely made available , and as a service they were usually unable to meet patient expectations (who believe a treatment might be made available), where in reality it almost certainly would not be available.
” 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 Unavailability of Schema-based Cognitive Behavioural Therapy on the NHS
Wider context from the report “5. In 2022 it was recognised by a Clinical Psychologist that Kate could benefit from Schema-based Cognitive Behavioural Therapy, which is not routinely available on the NHS .
The psychological review had been ordered by the Family Court, and funding for this course needed to be applied for.
Applying for funding involved requests to the Legal Aid Board, Integrated Care Board (Individual Funding Request), Wellbeing Service and Social Services, none of whom provided the funding, with each suggesting contacting one of the other agencies involved.
An experienced mental health clinician with many years’ experience described the ‘whole route as very complicated’ and ‘it was difficult to find a solution for funding’. In addition, funding was very rarely made available, and as a service they were usually unable to meet patient expectations (who believe a treatment might be made available), where in reality it almost certainly would not be available.
” 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 risk assessment of vulnerable parents’ mental health and physical wellbeing at Public Law Outline notification
Wider context from the report “2. It was identified that when Kate was informed there may be an application to the Family Court to place her children into care (using the Public Law Outline process), the impact of such a decision on her mental health, or physical wellbeing was not taken into consideration . As a recipient of a ‘Claires Law’ Domestic Violence Disclosure, it was acknowledged that she was of greater vulnerability, but no system is currently in place which allows a risk assessment to be undertaken at the time the Public Law Outline notification is given to a parent . The day after Kate was told of the Public Law Outline notification, she had intentionally crashed her car in an unsuccessful attempt to end her life, requiring 4 weeks in an Intensive Treatment Unit to recover from the serious injuries she received.
” 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 independent Social Services support for vulnerable parents
Wider context from the report “3. Once the Public Law Outline process was initiated, independent legal advice was provided, and a voluntary sector advocate supported Kate through the legal process. However, Katie received no independent support from Social Services , and had no independent professional to undertake a holistic review of her case, in light of her known circumstances and vulnerabilities. It was heard that mental health professionals had assumed that she had a Social Worker of her own, and expressed surprise when finding out that she did not.
” 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 independent professional holistic case review for vulnerable parents
Wider context from the report “3. Once the Public Law Outline process was initiated, independent legal advice was provided, and a voluntary sector advocate supported Kate through the legal process. However, Katie received no independent support from Social Services, and had no independent professional to undertake a holistic review of her case, in light of her known circumstances and vulnerabilities . It was heard that mental health professionals had assumed that she had a Social Worker of her own, and expressed surprise when finding out that she did not.
” Open source report
Concerns raised 1 Lack of a mandatory procedure for communicating known self-harm risk during unplanned release of remand 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
Christopher Alistair MacGillivray · 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
Christopher Alistair MacGillivray had a history of drug and alcohol issues, attempted suicide and self-harm, and a brain injury. After being remanded in custody and placed on ACCT procedures following reported thoughts of self-harm, he was released on bail without direct communication to his Probation Officer or Manager about his release and risk. He was found hanging at home two days later. The principal concern was the lack of mandatory procedures for communicating known self-harm risks when remand prisoners are released unexpectedly at short notice.
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 a mandatory procedure for communicating known self-harm risk during unplanned release of remand prisoners
Wider context from the report “(1) The prison service instruction (PSI) 64/2011 sets out the procedures that must be followed to manage prisoner safety. The Annex sets out a mandatory process for the planned release of a prisoner who has been on an ACCT.
Offender Management in Custody (OMiC) guidance provides for direct communication between Prison Offender Manager and Community Offender Manager in respect of prisoners at risk of self harm for SENTENCED PRISONERS ONLY.
(2) The PSI is silent in respect of unplanned releases for 'prisoners on remand' with a known risk of self-harm and who may be released at short notice.
There is no apparent direction/mandatory procedure for communication of the known risk of self-harm for unplanned release.
(3) There is a risk of future deaths of prisoners in the category as at para 2 above. Urgent amendment to PSI/Annex and OMiC is required to set out procedures that must be followed in the management of the unplanned release of prisoners at risk of self-harm/suicide.
” 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