29 May 2024 Hayley Jayne Cowan · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 4 Lack of guidance on staff bathroom arrangements while accompanying patients on leave View source Capacity-shaped local policies for Section 17 leave View source Lack of consistency in definitions of accompanied and escorted leave View source Inconsistent guidance on whether patients should remain within eyeline or at a reasonable distance during leave 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.
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AI-generated summary
Hayley Jayne Cowan · 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
Hayley Jayne Cowan was detained under Section 3 of the Mental Health Act and absconded during accompanied leave to a local shop on 3 June 2022. She was found deceased the following day after using drugs; concerns included inconsistent definitions and guidance for accompanied and escorted leave, including what staff should do if they needed to use the bathroom while accompanying a patient.
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 staff bathroom arrangements while accompanying patients on leave
Wider context from the report “The court heard evidence as to the lack of consistency and clarity for Mental Health trusts in understanding and defining how Section 17 leave should be conducted. This issue was highlighted in the paper published in December 2022 ████████, “NHS mental health services policies on leave for detained patients in England and Wales: A national audit.” Journal Psychiatric Mental Health Nursing 2023; 30: 719-730.
- Local policies appear to be shaped as a result of capacity
- There is a lack of consistency as to how “accompanied leave” and “escorted leave” are defined.
- Guidance as to whether a patient should remain in “eye-line” or at a “reasonable distance” is inconsistent and does not assist trusts in considering how trusts should work.
The Mental Health Act Codes of Practice, Guidance from the MOJ to Forensic providers and Trust policy are inconsistent. This is particularly the case in considering whether a patient needs to be within “eyeline” or a “reasonable distance” when on leave. There is also no guidance as to how trusts instruct staff on practical matters such as what to do if the staff member needs the bathroom whilst out with a patient.
” 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 Capacity-shaped local policies for Section 17 leave
Wider context from the report “The court heard evidence as to the lack of consistency and clarity for Mental Health trusts in understanding and defining how Section 17 leave should be conducted . This issue was highlighted in the paper published in December 2022 ████████, “NHS mental health services policies on leave for detained patients in England and Wales: A national audit.” Journal Psychiatric Mental Health Nursing 2023; 30: 719-730.
- Local policies appear to be shaped as a result of capacity
- There is a lack of consistency as to how “accompanied leave” and “escorted leave” are defined.
- Guidance as to whether a patient should remain in “eye-line” or at a “reasonable distance” is inconsistent and does not assist trusts in considering how trusts should work.
The Mental Health Act Codes of Practice, Guidance from the MOJ to Forensic providers and Trust policy are inconsistent. This is particularly the case in considering whether a patient needs to be within “eyeline” or a “reasonable distance” when on leave. There is also no guidance as to how trusts instruct staff on practical matters such as what to do if the staff member needs the bathroom whilst out with a patient.
” 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 consistency in definitions of accompanied and escorted leave
Wider context from the report “The court heard evidence as to the lack of consistency and clarity for Mental Health trusts in understanding and defining how Section 17 leave should be conducted. This issue was highlighted in the paper published in December 2022 ████████, “NHS mental health services policies on leave for detained patients in England and Wales: A national audit.” Journal Psychiatric Mental Health Nursing 2023; 30: 719-730.
- Local policies appear to be shaped as a result of capacity
- There is a lack of consistency as to how “accompanied leave” and “escorted leave” are defined.
- Guidance as to whether a patient should remain in “eye-line” or at a “reasonable distance” is inconsistent and does not assist trusts in considering how trusts should work.
The Mental Health Act Codes of Practice, Guidance from the MOJ to Forensic providers and Trust policy are inconsistent. This is particularly the case in considering whether a patient needs to be within “eyeline” or a “reasonable distance” when on leave. There is also no guidance as to how trusts instruct staff on practical matters such as what to do if the staff member needs the bathroom whilst out with a patient.
” 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 guidance on whether patients should remain within eyeline or at a reasonable distance during leave
Wider context from the report “The court heard evidence as to the lack of consistency and clarity for Mental Health trusts in understanding and defining how Section 17 leave should be conducted. This issue was highlighted in the paper published in December 2022 ████████, “NHS mental health services policies on leave for detained patients in England and Wales: A national audit.” Journal Psychiatric Mental Health Nursing 2023; 30: 719-730.
- Local policies appear to be shaped as a result of capacity
- There is a lack of consistency as to how “accompanied leave” and “escorted leave” are defined.
- Guidance as to whether a patient should remain in “eye-line” or at a “reasonable distance” is inconsistent and does not assist trusts in considering how trusts should work.
The Mental Health Act Codes of Practice, Guidance from the MOJ to Forensic providers and Trust policy are inconsistent. This is particularly the case in considering whether a patient needs to be within “eyeline” or a “reasonable distance” when on leave. There is also no guidance as to how trusts instruct staff on practical matters such as what to do if the staff member needs the bathroom whilst out with a patient.
” Open source report
29 May 2024 Elizabeth Sarah Jayne McCann · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 19 Inadequate management structure and oversight in the health and wellbeing college View source Failure to comply with GDPR in the health and wellbeing college View source Inadequate safeguarding provisions in health and wellbeing colleges View source Insufficient probation staffing capacity View source High proportion of probation officers with limited service and experience View source Limited information-sharing protocols between probation and partner services View source Lack of professional curiosity by senior GMP officers View source Poor-quality GMP investigations and reports View source Insufficient staffing of sexual offender management units View source Poor-quality investigations failing to generate organisational learning View source Failure to provide adequate supervision and support to newly qualified probation staff View source Insufficient professional curiosity among staff dealing with high-risk offenders View source Ineffective information-sharing protocols in health and wellbeing colleges View source Sexual offender management caseloads exceeding safe levels View source Insufficiently clear and understood risk-management protocols in health and wellbeing colleges View source Failure to escalate investigation reports for senior consideration View source Referrals to health and wellbeing services without risk-management protocols View source Inadequate systems for managing risk in the health and wellbeing college View source Lack of an information-sharing protocol between the health and wellbeing college and probation View source See 16 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Elizabeth Sarah Jayne McCann · 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
Elizabeth Sarah Jayne McCann was raped and murdered on 25 August 2022 at the home address of her murderer. The report identifies failures in risk assessment, information sharing, safeguarding, and management of a high-risk offender by the Health and Wellbeing College, Probation, and Greater Manchester Police. It also identifies concerns about excessive caseloads, inadequate staffing, supervision, recording, and organisational 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 Inadequate management structure and oversight in the health and wellbeing college
Wider context from the report “11. The Health and Wellbeing College in Tameside served 5 boroughs of Greater Manchester and was run by the Mental Health Trust. It was accepted by the Trust that the investigation report was of poor quality and an opportunity to learn lessons missed. This included the management structure, oversight , lack of an information sharing protocol with probation, the systems in the college for managing risk and sharing information and compliance with GDPR.
” 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 comply with GDPR in the health and wellbeing college
Wider context from the report “11. The Health and Wellbeing College in Tameside served 5 boroughs of Greater Manchester and was run by the Mental Health Trust. It was accepted by the Trust that the investigation report was of poor quality and an opportunity to learn lessons missed. This included the management structure, oversight, lack of an information sharing protocol with probation, the systems in the college for managing risk and sharing information and compliance with GDPR .
” 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 safeguarding provisions in health and wellbeing colleges
Wider context from the report “10. The inquest was told that Health and Well Being Colleges could provide effective support for the communities they served. They were a national model. However, if they were to be open to all it was essential that they were structured in such a way that risk was effectively managed with clear, documented protocols understood by all in place. There was also a need for effective information sharing protocols and effective well understood safeguarding provisions .
” 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 probation staffing capacity
Wider context from the report “1. The inquest heard evidence that the probation staff were carrying significant caseloads . This was due to challenges in recruiting sufficient staff . The evidence was that there is still a national shortage of probation officers . Steps have been taken to recruit and train further probation officers which provides some assistance but means that overall, a significant number of probation officers are young in service and experience.
” 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 High proportion of probation officers with limited service and experience
Wider context from the report “1. The inquest heard evidence that the probation staff were carrying significant caseloads. This was due to challenges in recruiting sufficient staff. The evidence was that there is still a national shortage of probation officers. Steps have been taken to recruit and train further probation officers which provides some assistance but means that overall, a significant number of probation officers are young in service and experience .
” 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 Limited information-sharing protocols between probation and partner services
Wider context from the report “4. Clear Information Sharing protocols between Probation and such groups as drug and alcohol services were limited . Without clear agreements understood by both sides there was a significant risk that crucial information that impacted risk assessments would not be 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 Lack of professional curiosity by senior GMP officers
Wider context from the report “8. There was no evidence before the inquest of any professional curiosity by senior GMP officers as to the role of GMP and if lessons could be learnt . It was unclear as to why senior officers were unsighted .
” 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 Poor-quality GMP investigations and reports
Wider context from the report “7. The GMP investigation into their role in relation to Elizabeth’s death was poor in quality and there was no evidence that any senior officer had considered the report. The inquest was told that the quality and lack of referral upwards of a report was not unique to Elizabeth’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 Insufficient staffing of sexual offender management units
Wider context from the report “5. The inquest was told that nationally a significant number of police forces were struggling to adequately staff their Sexual Offender Management Units . As a consequence, the level of supervision of sex offenders in the community was being risk managed posing a risk to communities.
” 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 Poor-quality investigations failing to generate organisational learning
Wider context from the report “11. The Health and Wellbeing College in Tameside served 5 boroughs of Greater Manchester and was run by the Mental Health Trust. It was accepted by the Trust that the investigation report was of poor quality and an opportunity to learn lessons missed . This included the management structure, oversight, lack of an information sharing protocol with probation, the systems in the college for managing risk and sharing information and compliance with GDPR.
” 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 adequate supervision and support to newly qualified probation staff
Wider context from the report “2. The evidence before the inquest was that it was important that newly qualified probation staff were closely supervised and supported by their managers . Without that supervision performance issues identified by the trackers were not being tackled . Ensuring this had been and was challenging as the number of staff line managed by senior probation officers had been too high . This was being addressed but was only achievable if sufficient senior staff were retained.
” 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 professional curiosity among staff dealing with high-risk offenders
Wider context from the report “9. It was accepted that there needed to be a level of professional curiosity by staff dealing with high-risk offenders such as in this case and that training for probation officers and police staff needed to reinforce that.
” 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 Ineffective information-sharing protocols in health and wellbeing colleges
Wider context from the report “10. The inquest was told that Health and Well Being Colleges could provide effective support for the communities they served. They were a national model. However, if they were to be open to all it was essential that they were structured in such a way that risk was effectively managed with clear, documented protocols understood by all in place. There was also a need for effective information sharing protocols and effective well understood safeguarding provisions.
” 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 Sexual offender management caseloads exceeding safe levels
Wider context from the report “6. In the case of Greater Manchester Police, the staffing issues had been known by senior managers for a number of years (many years before Covid) and a decision taken to risk mange far below the appropriate staffing numbers taken. The consequence was that the staff in the unit could not effectively manage their caseloads that were far in excess of the recommended level . The numbers in the unit were increasing but the caseloads were still 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 Insufficiently clear and understood risk-management protocols in health and wellbeing colleges
Wider context from the report “10. The inquest was told that Health and Well Being Colleges could provide effective support for the communities they served. They were a national model. However, if they were to be open to all it was essential that they were structured in such a way that risk was effectively managed with clear, documented protocols understood by all in place . There was also a need for effective information sharing protocols and effective well understood safeguarding provisions.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate investigation reports for senior consideration
Wider context from the report “7. The GMP investigation into their role in relation to Elizabeth’s death was poor in quality and there was no evidence that any senior officer had considered the report . The inquest was told that the quality and lack of referral upwards of a report was not unique to Elizabeth’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 Referrals to health and wellbeing services without risk-management protocols
Wider context from the report “3. Evidence before the inquest was that if probation referred clients under supervision to places such as the Health and Wellbeing College this would, if not implemented effectively pose a significant risk to vulnerable users of such institutions. If referrals were made without a protocol being in place that dealt with managing risk then the risk posed increased further.
” 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 systems for managing risk in the health and wellbeing college
Wider context from the report “11. The Health and Wellbeing College in Tameside served 5 boroughs of Greater Manchester and was run by the Mental Health Trust. It was accepted by the Trust that the investigation report was of poor quality and an opportunity to learn lessons missed. This included the management structure, oversight, lack of an information sharing protocol with probation, the systems in the college for managing risk and sharing information and compliance with GDPR.
” 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 information-sharing protocol between the health and wellbeing college and probation
Wider context from the report “11. The Health and Wellbeing College in Tameside served 5 boroughs of Greater Manchester and was run by the Mental Health Trust. It was accepted by the Trust that the investigation report was of poor quality and an opportunity to learn lessons missed. This included the management structure, oversight, lack of an information sharing protocol with probation , the systems in the college for managing risk and sharing information and compliance with GDPR.
” Open source report
21 May 2024 Christine MCDONALD · Prevention of Future Deaths report Cheshire
View report summary
Concerns raised 2 Failure to use emergency response codes View source Inability of training to fully prepare first-on-scene staff for emergencies 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
Christine MCDONALD · 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
Christine McDonald died in hospital on 3 March 2019 after being found unresponsive in her prison cell with a ligature. The report identified concerns about failures in communication and information sharing, failure to assess and respond to her healthcare needs, and failures relating to treatment of her drug dependency. The emergency response code was not used, causing delays in providing emergency equipment and medical treatment, although this was not found to have contributed to her death.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to use emergency response codes
Wider context from the report “I heard evidence during the course of this Inquest in respect of the process for using the emergency response codes , this is something which arises in many cases of this type. I heard evidence in this case that the emergency response code was not used and as a consequence, those responding to the call were not prepared in the sense of emergency equipment, nor were they prepared mentally for the situation they had been asked to attend.
I heard evidence in respect of the training and integrity testing that is now conducted to try to simulate the unexpected nature of an emergency, the evidence being that it is very difficult and that no training can fully prepare those staff who are first on scene for what they may find.
I also heard evidence relating to measures within the control room, which might assist those first on scene in terms of the use of emergency codes and provide additional safeguards for those whose lives are at 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 Inability of training to fully prepare first-on-scene staff for emergencies
Wider context from the report “I heard evidence during the course of this Inquest in respect of the process for using the emergency response codes, this is something which arises in many cases of this type. I heard evidence in this case that the emergency response code was not used and as a consequence, those responding to the call were not prepared in the sense of emergency equipment, nor were they prepared mentally for the situation they had been asked to attend.
I heard evidence in respect of the training and integrity testing that is now conducted to try to simulate the unexpected nature of an emergency, the evidence being that it is very difficult and that no training can fully prepare those staff who are first on scene for what they may find .
I also heard evidence relating to measures within the control room, which might assist those first on scene in terms of the use of emergency codes and provide additional safeguards for those whose lives are at risk.
” Open source report
20 May 2024 James Furlong and 2 others · Prevention of Future Deaths report Central Criminal Court
View report summary
Concerns raised 6 Failure to maintain and disseminate an adequate intelligence picture View source Failure to provide an adequate and integrated response to identified risk View source Failure to address consequential risks created by inadequate intelligence dissemination View source Failure to provide adequate secondary mental healthcare in prison View source Failure to provide adequate mental healthcare in the community View source Failure to avoid discounting extremist risk because of personality disorder and PTSD symptoms View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
James Furlong 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
James Furlong, Joseph Ritchie-Bennett and David Wails were murdered by Khairi Saadallah in a premeditated attack in Forbury Gardens, Reading, on 20 June 2020. The principal concerns were failures by multiple bodies to assess and share intelligence about Saadallah’s risks, provide an adequate integrated response, and provide adequate mental healthcare in the community and prison; the report states these failures probably or possibly contributed to the three 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 Failure to maintain and disseminate an adequate intelligence picture
Wider context from the report “The critical context of this Report is that there were notable failures on the part of multiple bodies which both probably and possibly contributed to the three deaths. These have been explained in extenso in my Factual Findings. In summary form, however, there was a failure to:
a) assess the intelligence in its entirety (there was an extensive intelligence history concerning KS’s extremism and capacity for violence) and then share the intelligence appropriately; instead – certainly on occasion – limited pieces of information only were made available, which were thereby rendered potentially misleading;
b) address the substantial consequential risks created by this lack of dissemination of the overarching intelligence picture (which included KS’s extremist views and associations, military training and violent impulsivity, which were potentiated by his personality disorder);
c) provide an adequate and integrated response to the true risk posed by KS, based on a consideration of the entirety of the relevant material; and
d) offer KS adequate mental healthcare in the community and secondary mental healthcare in prison.
The failures principally involved the Home Office, Counter Terrorism Police South-East (“CTPSE”), HMPPS, BHFT and MPFT. There were concurrent deficiencies in the approach adopted within the Prevent, Pathfinder and MAPPA schemes. A common enduring error during the relevant period was the tendency to downplay or discount KS’s extremist risk on account of his EUPD and symptoms of PTSD.
The failure to maintain and disseminate an adequate intelligence picture (the Secretary of State for the Home Department, the Secretary of State for Justice, the Chief Constable of Thames Valley Police)
The failure to provide KS adequate mental healthcare in the community and to provide KS adequate secondary mental healthcare in prison (the Secretary of State for Justice, Berkshire Healthcare NHS Foundation Trust and Midlands Partnership University NHS Foundation Trust)
” 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 an adequate and integrated response to identified risk
Wider context from the report “The critical context of this Report is that there were notable failures on the part of multiple bodies which both probably and possibly contributed to the three deaths. These have been explained in extenso in my Factual Findings. In summary form, however, there was a failure to:
a) assess the intelligence in its entirety (there was an extensive intelligence history concerning KS’s extremism and capacity for violence) and then share the intelligence appropriately; instead – certainly on occasion – limited pieces of information only were made available, which were thereby rendered potentially misleading;
b) address the substantial consequential risks created by this lack of dissemination of the overarching intelligence picture (which included KS’s extremist views and associations, military training and violent impulsivity, which were potentiated by his personality disorder);
c) provide an adequate and integrated response to the true risk posed by KS, based on a consideration of the entirety of the relevant material; and
d) offer KS adequate mental healthcare in the community and secondary mental healthcare in prison.
The failures principally involved the Home Office, Counter Terrorism Police South-East (“CTPSE”), HMPPS, BHFT and MPFT. There were concurrent deficiencies in the approach adopted within the Prevent, Pathfinder and MAPPA schemes. A common enduring error during the relevant period was the tendency to downplay or discount KS’s extremist risk on account of his EUPD and symptoms of PTSD.
The failure to maintain and disseminate an adequate intelligence picture (the Secretary of State for the Home Department, the Secretary of State for Justice, the Chief Constable of Thames Valley Police)
The failure to provide KS adequate mental healthcare in the community and to provide KS adequate secondary mental healthcare in prison (the Secretary of State for Justice, Berkshire Healthcare NHS Foundation Trust and Midlands Partnership University NHS Foundation Trust)
” 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 address consequential risks created by inadequate intelligence dissemination
Wider context from the report “The critical context of this Report is that there were notable failures on the part of multiple bodies which both probably and possibly contributed to the three deaths. These have been explained in extenso in my Factual Findings. In summary form, however, there was a failure to:
a) assess the intelligence in its entirety (there was an extensive intelligence history concerning KS’s extremism and capacity for violence) and then share the intelligence appropriately; instead – certainly on occasion – limited pieces of information only were made available, which were thereby rendered potentially misleading;
b) address the substantial consequential risks created by this lack of dissemination of the overarching intelligence picture (which included KS’s extremist views and associations, military training and violent impulsivity, which were potentiated by his personality disorder);
c) provide an adequate and integrated response to the true risk posed by KS, based on a consideration of the entirety of the relevant material; and
d) offer KS adequate mental healthcare in the community and secondary mental healthcare in prison.
The failures principally involved the Home Office, Counter Terrorism Police South-East (“CTPSE”), HMPPS, BHFT and MPFT. There were concurrent deficiencies in the approach adopted within the Prevent, Pathfinder and MAPPA schemes. A common enduring error during the relevant period was the tendency to downplay or discount KS’s extremist risk on account of his EUPD and symptoms of PTSD.
The failure to maintain and disseminate an adequate intelligence picture (the Secretary of State for the Home Department, the Secretary of State for Justice, the Chief Constable of Thames Valley Police)
The failure to provide KS adequate mental healthcare in the community and to provide KS adequate secondary mental healthcare in prison (the Secretary of State for Justice, Berkshire Healthcare NHS Foundation Trust and Midlands Partnership University NHS Foundation Trust)
” 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 adequate secondary mental healthcare in prison
Wider context from the report “The critical context of this Report is that there were notable failures on the part of multiple bodies which both probably and possibly contributed to the three deaths. These have been explained in extenso in my Factual Findings. In summary form, however, there was a failure to:
a) assess the intelligence in its entirety (there was an extensive intelligence history concerning KS’s extremism and capacity for violence) and then share the intelligence appropriately; instead – certainly on occasion – limited pieces of information only were made available, which were thereby rendered potentially misleading;
b) address the substantial consequential risks created by this lack of dissemination of the overarching intelligence picture (which included KS’s extremist views and associations, military training and violent impulsivity, which were potentiated by his personality disorder);
c) provide an adequate and integrated response to the true risk posed by KS, based on a consideration of the entirety of the relevant material; and
d) offer KS adequate mental healthcare in the community and secondary mental healthcare in prison.
The failures principally involved the Home Office, Counter Terrorism Police South-East (“CTPSE”), HMPPS, BHFT and MPFT. There were concurrent deficiencies in the approach adopted within the Prevent, Pathfinder and MAPPA schemes. A common enduring error during the relevant period was the tendency to downplay or discount KS’s extremist risk on account of his EUPD and symptoms of PTSD.
The failure to maintain and disseminate an adequate intelligence picture (the Secretary of State for the Home Department, the Secretary of State for Justice, the Chief Constable of Thames Valley Police)
The failure to provide KS adequate mental healthcare in the community and to provide KS adequate secondary mental healthcare in prison (the Secretary of State for Justice, Berkshire Healthcare NHS Foundation Trust and Midlands Partnership University NHS Foundation Trust)
” 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 adequate mental healthcare in the community
Wider context from the report “The critical context of this Report is that there were notable failures on the part of multiple bodies which both probably and possibly contributed to the three deaths. These have been explained in extenso in my Factual Findings. In summary form, however, there was a failure to:
a) assess the intelligence in its entirety (there was an extensive intelligence history concerning KS’s extremism and capacity for violence) and then share the intelligence appropriately; instead – certainly on occasion – limited pieces of information only were made available, which were thereby rendered potentially misleading;
b) address the substantial consequential risks created by this lack of dissemination of the overarching intelligence picture (which included KS’s extremist views and associations, military training and violent impulsivity, which were potentiated by his personality disorder);
c) provide an adequate and integrated response to the true risk posed by KS, based on a consideration of the entirety of the relevant material; and
d) offer KS adequate mental healthcare in the community and secondary mental healthcare in prison.
The failures principally involved the Home Office, Counter Terrorism Police South-East (“CTPSE”), HMPPS, BHFT and MPFT. There were concurrent deficiencies in the approach adopted within the Prevent, Pathfinder and MAPPA schemes. A common enduring error during the relevant period was the tendency to downplay or discount KS’s extremist risk on account of his EUPD and symptoms of PTSD.
The failure to maintain and disseminate an adequate intelligence picture (the Secretary of State for the Home Department, the Secretary of State for Justice, the Chief Constable of Thames Valley Police)
The failure to provide KS adequate mental healthcare in the community and to provide KS adequate secondary mental healthcare in prison (the Secretary of State for Justice, Berkshire Healthcare NHS Foundation Trust and Midlands Partnership University NHS Foundation Trust)
” 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 avoid discounting extremist risk because of personality disorder and PTSD symptoms
Wider context from the report “The critical context of this Report is that there were notable failures on the part of multiple bodies which both probably and possibly contributed to the three deaths. These have been explained in extenso in my Factual Findings. In summary form, however, there was a failure to:
a) assess the intelligence in its entirety (there was an extensive intelligence history concerning KS’s extremism and capacity for violence) and then share the intelligence appropriately; instead – certainly on occasion – limited pieces of information only were made available, which were thereby rendered potentially misleading;
b) address the substantial consequential risks created by this lack of dissemination of the overarching intelligence picture (which included KS’s extremist views and associations, military training and violent impulsivity, which were potentiated by his personality disorder);
c) provide an adequate and integrated response to the true risk posed by KS, based on a consideration of the entirety of the relevant material; and
d) offer KS adequate mental healthcare in the community and secondary mental healthcare in prison.
The failures principally involved the Home Office, Counter Terrorism Police South-East (“CTPSE”), HMPPS, BHFT and MPFT. There were concurrent deficiencies in the approach adopted within the Prevent, Pathfinder and MAPPA schemes. A common enduring error during the relevant period was the tendency to downplay or discount KS’s extremist risk on account of his EUPD and symptoms of PTSD.
The failure to maintain and disseminate an adequate intelligence picture (the Secretary of State for the Home Department, the Secretary of State for Justice, the Chief Constable of Thames Valley Police)
The failure to provide KS adequate mental healthcare in the community and to provide KS adequate secondary mental healthcare in prison (the Secretary of State for Justice, Berkshire Healthcare NHS Foundation Trust and Midlands Partnership University NHS Foundation Trust)
” 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 Issue prison intelligence-assessment guidance and a template for comprehensive MAPPA Level 2/3 information-sharing reports.
Verbatim wording from the response “50. In your factual findings you identified that there was an incomplete intelligence picture for KS. This included prison intelligence which did not reach KS’s COM. The National Intelligence Unit (NIU) within HMPPS has reviewed the way prisons share security information and intelligence within MAPPA, specifically when contributing to MAPPA level 2 and 3 meetings.” Source location Response from Ministry of Justice
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 Improve Pathfinder delivery by redefining partner responsibilities and linking Pathfinder forums with the Counter Terrorism Clinical Consultancy Service.
Verbatim wording from the response “38. As part of ongoing continuous improvement activities, HMPPS is taking steps to improve how Pathfinder is delivered including re-defining the roles and responsibilities of Pathfinder partners. These include links that have been established between Pathfinder forums and the Counter Terrorism Clinical Consultancy Service (CTCCS) which replaced Vulnerability Support Hubs in April 2024. CTCCS are embedded multi-disciplinary mental health teams that work with individuals who are deemed susceptible to radicalisation and who also present as having mental health issues.” Source location Response from Ministry of Justice
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 Plan further Pathfinder reforms to review referral thresholds, align terrorist-risk understanding and establish a National Pathfinder process with senior oversight.
Verbatim wording from the response “41. As part of ongoing continuous improvement activities, HMPPS and partners are planning to make further improvements to Pathfinder. These reforms will build on the established foundations of multi-agency, CT-specialist case management processes already operating in the prison and probation sector, developing these further to improve our ability to make agile, informed decisions around CT case management, by creating timely, secure access to the right information and intelligence, at the right time, by the right people.” Source location Response from Ministry of Justice
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 Implement MAPPA quality assurance through audits of referrals and Level 2/3 meeting minutes, with resulting learning and actions disseminated.
Verbatim wording from the response “47. Local Strategic Management Boards (SMBs) are responsible for delivering MAPPA within their respective Criminal Justice areas. These boards provide governance and are required to have quality assurance processes in place. Thames Valley MAPPA SMB has implemented quality assurance of the MAPPA process. This has included audits on 18 March 2024 and 15 April 2024 for referrals rejected by the thresholding panel and audit of MAPPA Minutes on 19 February 2024 for the management of MAPPA Level 2/3 meetings. These aspects were specifically chosen as they had been identified as not working well by the author of the MAPPA SCR.” Source location Response from Ministry of Justice
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 Issue and require use of the Pathfinder Guidance Framework and Controls and Interventions Matrix for active terrorist-risk cases, supported by trained assessors.
Verbatim wording from the response “33. In October 2022, the Pathfinder Guidance Framework (PGF) Operational Delivery Guidance was issued. The PGF assesses susceptibility to extremism and what is required by way of interventions to address this. It has been designed to help document, structure and support decision making and the case management of terrorist risk offenders. It should be completed alongside the Controls and Interventions Matrix (CIM). It should be used by CT Specialists to guide consideration of the extremism concerns and to help direct further actions and interventions. It was issued to trained assessors, supervisors and staff involved in the management of terrorist risk cases across HMPPS. The PGF is an assessment tool which must be completed for all terrorist risk offenders who have been made an active case of concern at Pathfinder. It must be completed within 8 weeks of the offender being made ‘active’.” Source location Response from Ministry of Justice
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 Test and evaluate an enhanced mental-health support model in Approved Premises for high-risk probation leavers with complex needs.
Verbatim wording from the response “i) Testing and evaluating a new model within Approved Premises (APs), enabled by £2.4 million funding over three years up to 2025. This provides targeted, enhanced mental health support to high-risk probation leavers with the most complex needs, building a clear bridge into services in the community, as recommended in the Rapid Review. The initial formal evaluation review will be available in Autumn 2024.” Source location Response from Ministry of Justice
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 Create MAPPA Category 4 and amend information-sharing powers to cover terrorism-risk offenders and relevant agencies.
Verbatim wording from the response “55. There has also been an independent review of MAPPA by Jonathan Hall,⁹ as a result of which a discrete new MAPPA category, Category 4 was created. This was to ensure that all offenders convicted of terrorism offences are automatically referred to and managed under MAPPA and to enable offenders who are assessed as presenting a terrorism risk to be managed under MAPPA, even where they have not been convicted of terrorism offences. We also introduced amendments to part 13 of the Criminal and Justice Act 2003¹⁰ to put beyond doubt Duty to Co-operate (DTC) agencies’ powers to share information under MAPPA and extended these powers to cover any agency the Responsible Authority considers may contribute to the assessment and management of the risks presented by MAPPA offenders, for example GPs.” Source location Response from Ministry of Justice
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 and operate the Pathfinder Dormant Review procedure, including pre-release review, standing-agenda consideration and multi-agency risk decisions.
Verbatim wording from the response “23. In March 2021, the Dormant Review Standard Operating Procedure (DR SOP) was introduced. This provided detailed guidance as to when and how to complete a review of a dormant Pathfinder case, and who should do it. Previously, staff were reliant on the very limited detail about the Dormant Review requirement that was included in the Managing Extremism Policy Framework (Annex C of Managing Extremism Amongst Offenders in Custody and Annex L of Managing Extremism Amongst Offenders in the Community). The Dormant Review process ensures that those who have previously” Source location Response from Ministry of Justice
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 Issue guidance and training to improve healthcare engagement and practitioner understanding of mental-health needs in Pathfinder risk management.
Verbatim wording from the response “36. In June 2022, HMPPS and NHS England jointly issued guidance for healthcare staff entitled “Increasing the Engagement of Prison Integrated Healthcare Teams in Pathfinder”. This followed a JEXU Review of mental health provision after the attacks in Forbury Gardens. The review identified the need to improve the engagement of healthcare teams in Pathfinder. The aim of this guidance has been to encourage healthcare attendance at case management meetings in custody, and in turn to help ensure mental health information is being used to inform the assessment and management of terrorist risk. Follow-up surveys on the implementation of this guidance show an increase of 21 percentage points in healthcare’s attendance at Pathfinder meetings from 59% in the first half of 2022 to 80% in the second half of 2022. The surveys were not mandatory but provide an indicative representation.” Source location Response from Ministry of Justice
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 Replace Mercury with the Intelligence Management Service and roll out probation access to prison intelligence.
Verbatim wording from the response “15. Other new services are being developed to share information across systems to make sure that HMPPS staff have the information that they need. Whilst some of these services are still in development, several have been launched since 2020, including in particular the Pathfinder IT service which supports the management of terrorism-related nominals across the prison and probation services. Pathfinder IT is addressed in more detail at paragraphs 30 to 32 below.” Source location Response from Ministry of Justice
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 Publish guidance requiring prison staff to link Mercury intelligence records to nominal records, including after release.
Verbatim wording from the response “19. Whilst the Mercury system is still operational, there is also a plan to publish specific guidance to ensure that all prison staff are aware that Mercury Intelligence Records need to be linked to a nominal’s record, even if the subject is no longer in custody. This will be published by Autumn 2024. The working assumption is that intelligence on former prisoners is linked to their records, and it is the case that the vast majority of information is correctly linked. However, this requirement is not formally stated anywhere within HMPPS training or processes. This new guidance will address this lacuna.” Source location Response from Ministry of Justice
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 Operational delivery of mental healthcare is the responsibility of relevant NHS trusts.
Verbatim wording from the response “1. Whilst the operational delivery of mental healthcare is for the relevant NHS trusts, this case raises wider concerns about the continuity of healthcare provision between custody and the community, the treatment and management of offenders with personality disorders and the support afforded to probation practitioners in working with offenders with complex mental health and substance or personality issues.” Source location Response from Ministry of Justice
Open published response
×
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 HMPPS has limited levers to secure healthcare attendance at Pathfinder meetings or escalate gaps in mental health services.
Verbatim wording from the response “35. Terrorist and terrorist-risk offenders commonly have multiple, complex needs and face difficulties in accessing services. As healthcare does not allocate treatment based on national security risk but rather on clinical need, terrorist and terrorist-risk offenders cannot be auto-prioritised. To date, HMPPS has limited levers to use to secure healthcare attendance at Pathfinder and escalate issues where mental health services are lacking.” Source location Response from Ministry of Justice
Open published response
Concerns raised 2 Failure to provide timely training and guidance on the appropriate use of Code Blue and Code Red communications during a medical emergency View source Failure to provide timely training and guidance on entering a cell during a medical emergency View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Luke Mikael PEARCE · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Luke Pearce was found hanging in his cell at HMP/YOI Swinfen Hall on 6 April 2023 and was pronounced dead after staff and paramedics performed CPR. The report identified delays in entering the cell, removing the ligature and starting CPR, and raised concerns that relevant emergency training and guidance, including the use of Code Blue and Code Red communications, was not being delivered to appropriate staff in a timely manner.
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 timely training and guidance on the appropriate use of Code Blue and Code Red communications during a medical emergency
Wider context from the report “That relevant training and guidance to equip staff to understand when and how to enter a cell in a medical emergency, and the appropriate use of Code Blue and Code Red communications in a medical emergency , is not being delivered in a timely manner to appropriate 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 timely training and guidance on entering a cell during a medical emergency
Wider context from the report “That relevant training and guidance to equip staff to understand when and how to enter a cell in a medical emergency , and the appropriate use of Code Blue and Code Red communications in a medical emergency, is not being delivered in a timely manner to appropriate staff .
” Open source report
10 May 2024 Paul Edward DAY · Prevention of Future Deaths report Derby and Derbyshire
View report summary
Concerns raised 2 Inappropriate CPR guidance on rigor mortis exclusions in prisons without 24-hour healthcare staffing View source Failure to train prison officers to assess and recognise rigor mortis for CPR decisions 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
Paul Edward DAY · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Paul Edward Day was found collapsed and unresponsive in a prison toilet cubicle on 22 March 2017 after exposure to cold running water from a broken pipe. Prison officers did not attempt CPR because they believed he was in rigor mortis; CPR was started about 15 minutes later, but he subsequently died in hospital in the early hours of 23 March. The principal concern was that national prison CPR guidance included rigor mortis as an exclusion, despite prison officers not being trained to recognise it, creating a risk that CPR could be withheld in prisons without 24-hour healthcare staffing.
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 Inappropriate CPR guidance on rigor mortis exclusions in prisons without 24-hour healthcare staffing
Wider context from the report “1. I understand that the prison guidance re CPR which I have referenced, is in effect guidance provided nationally to all prisons. The inclusion of rigor mortis in the exclusions for CPR is something of an outlier as compared to the other reasons which would clearly and obviously evidence that death had occurred, even to someone without first aid training. In those prisons without 24-hour healthcare staffing prison officer staff are operating under guidance that they are not trained to be able to follow (re rigor mortis). In prisons with 24-hour healthcare staffing it is likely that healthcare staff would attend a resuscitation incident.
2. Given the current guidance, in those prisons without 24-hour healthcare staffing, and where prison officer staff attend a prisoner in a state of collapse who is not breathing and is pulseless, there is the clear potential to mistakenly assess the person to be in a state of rigor mortis, and thus miss the opportunity to undertake CPR and potentially prevent death, because quite clearly they have not been trained to assess for and recognise rigor mortis. This was very clearly illustrated in Mr Day’s inquest.
3. The current CPR guidance does not appear to be appropriate for those prisons without 24-hour healthcare staffing , and in my view presents the real risk that future deaths could occur unless action is 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 Failure to train prison officers to assess and recognise rigor mortis for CPR decisions
Wider context from the report “1. I understand that the prison guidance re CPR which I have referenced, is in effect guidance provided nationally to all prisons. The inclusion of rigor mortis in the exclusions for CPR is something of an outlier as compared to the other reasons which would clearly and obviously evidence that death had occurred, even to someone without first aid training. In those prisons without 24-hour healthcare staffing prison officer staff are operating under guidance that they are not trained to be able to follow (re rigor mortis) . In prisons with 24-hour healthcare staffing it is likely that healthcare staff would attend a resuscitation incident.
2. Given the current guidance, in those prisons without 24-hour healthcare staffing, and where prison officer staff attend a prisoner in a state of collapse who is not breathing and is pulseless, there is the clear potential to mistakenly assess the person to be in a state of rigor mortis, and thus miss the opportunity to undertake CPR and potentially prevent death, because quite clearly they have not been trained to assess for and recognise rigor mortis . This was very clearly illustrated in Mr Day’s inquest.
3. The current CPR guidance does not appear to be appropriate for those prisons without 24-hour healthcare staffing, and in my view presents the real risk that future deaths could occur unless action is taken.
” Open source report
12 Apr 2024 Scott William James Rider · Prevention of Future Deaths report Milton Keynes
View report summary
Concerns raised 1 Failure to review prisoners sentenced to IPP 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
Scott William James Rider · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Scott William James Rider was a prisoner at HMP Woodhill who had been serving an indeterminate Imprisonment for Public Protection sentence for 17 and a half years. On 13 June 2022, he was found hanging in his cell with a ligature around his neck, and the inquest concluded that he died by suicide. The concerns included limited hope of release among IPP prisoners, uncertainty about the continuing length of his sentence, inadequate staffing levels, and the risk of further deaths if IPP prisoners were not reviewed.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to review prisoners sentenced to IPP
Wider context from the report “One of the findings of the Prisons and Probation Ombudsman was that Mr Rider was one of many IPP prisoners struggling to progress in his sentence and had limited hope for release. The Governor of the prison in her evidence to me, spoke about indeterminate sentences and said "In my personal view they are indefensible". She went on to say "We find that some of the most challenging behaviours are from this group of men who feel trapped".
The governor also commented that if I were to submit a Regulation 28 report to the Minister for Prisons; "most Prison Governors would welcome that intervention." On the 9th September 2005 Mr Rider received an Imprisonment for Public Protection (IPP) sentence with a tariff of 23 months; at the time of his death he had served seventeen and half years and had given up all hope of release. On any consideration of the circumstances of Mr Rider's death one has to conclude that his treatment was inhumane and indefensible and that if action is not taken to review all prisoners sentenced to IPP then there is a risk of further deaths occurring .
” Open source report
Concerns raised 3 Failure of probation officers to understand processes for suspending and cancelling parole licence supervision View source Failure of the referral system to refer eligible people for parole licence cancellation View source Failure of probation officers to understand and remain alert to suicide and self-harm risk in IPP offenders 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
Francis Ian 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
Francis Williams, who was subject to an imprisonment for public protection sentence, was evicted from accommodation after struggling with alcohol and was facing possible recall to prison. He told his probation officer he intended to kill himself and was found dead from a heroin overdose in a tent in Bognor Regis on 28 January 2023. The report identified concerns about probation officers recognising suicide and self-harm risks among IPP offenders and about processes for suspending and cancelling parole licence supervision.
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 of probation officers to understand processes for suspending and cancelling parole licence supervision
Wider context from the report “My investigation reveals two relevant concerns:
1. That probation officers need to understand, and be constantly alert to, the risk of suicide/self-harm in IPP offenders. It is clear from Mr Williams’ case, but also from other cases and other evidence, that this cohort often experiences a particular kind of despair. That is fuelled in part by the particular sense of unfairness that they feel about being on an IPP at all, now the sentence has been abolished and all agree that IPP sentences were a terrible idea. The other factor is the absence of hope of ever getting off it.
2. Linked to that second point, it is crucial that probation officers are also fully versed in the processes for suspending parole licence supervision and then cancelling it altogether . One of the real tragedies of Mr Williams’ case is that in 2019 he had been free for ten years, so he should have been referred for licence cancellation. It did not happen, and it is not clear why, but it may have been because no-one was actively looking at him given that his supervision had been suspended. In any event, the referral system did not work and Mr Williams was never referred, at any stage, for cancellation.
Mr Williams was then overtaken by lockdown and related matters in 2020, which pulled the rug on his business and other protective factors, and he then returned to supervision and ultimately recall to prison. Following release in 2022 he was still not referred, and even at the end of that year - which I note was now after the amendments to s.31A of the Crime (Sentences) Act 1997 and the introduction of an entitlement to automatic referral to the Parole Board for cancellation – no referral had been made. By then, of course, Mr Williams might have found cancellation much more difficult. However, it is noteworthy that even with those well publicised changes, which Mr Williams had heard about, his probation officer seemed to be struggling to find out how the process worked (entries in the probation records in December 2022 confirm).
Again, the point is that there is a particular kind of despair among the IPP cohort. The main safeguard is the facility for getting off that, or at least giving these men hope that they may be able to get off it. Mr Williams and his probation officer were struggling to find out how to access even that limited (and automatic) safeguard. It was very shortly after that (within a month or so) that he took his life. The jury was clear that the fact of the IPP caused his state of mind and so caused his death.
It seems to me that these two concerns at least give rise to a training need. There may be more. But I consider that action should be 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 Failure of the referral system to refer eligible people for parole licence cancellation
Wider context from the report “My investigation reveals two relevant concerns:
1. That probation officers need to understand, and be constantly alert to, the risk of suicide/self-harm in IPP offenders. It is clear from Mr Williams’ case, but also from other cases and other evidence, that this cohort often experiences a particular kind of despair. That is fuelled in part by the particular sense of unfairness that they feel about being on an IPP at all, now the sentence has been abolished and all agree that IPP sentences were a terrible idea. The other factor is the absence of hope of ever getting off it.
2. Linked to that second point, it is crucial that probation officers are also fully versed in the processes for suspending parole licence supervision and then cancelling it altogether. One of the real tragedies of Mr Williams’ case is that in 2019 he had been free for ten years, so he should have been referred for licence cancellation. It did not happen, and it is not clear why, but it may have been because no-one was actively looking at him given that his supervision had been suspended. In any event, the referral system did not work and Mr Williams was never referred, at any stage, for cancellation .
Mr Williams was then overtaken by lockdown and related matters in 2020, which pulled the rug on his business and other protective factors, and he then returned to supervision and ultimately recall to prison. Following release in 2022 he was still not referred, and even at the end of that year - which I note was now after the amendments to s.31A of the Crime (Sentences) Act 1997 and the introduction of an entitlement to automatic referral to the Parole Board for cancellation – no referral had been made. By then, of course, Mr Williams might have found cancellation much more difficult. However, it is noteworthy that even with those well publicised changes, which Mr Williams had heard about, his probation officer seemed to be struggling to find out how the process worked (entries in the probation records in December 2022 confirm).
Again, the point is that there is a particular kind of despair among the IPP cohort. The main safeguard is the facility for getting off that, or at least giving these men hope that they may be able to get off it. Mr Williams and his probation officer were struggling to find out how to access even that limited (and automatic) safeguard. It was very shortly after that (within a month or so) that he took his life. The jury was clear that the fact of the IPP caused his state of mind and so caused his death.
It seems to me that these two concerns at least give rise to a training need. There may be more. But I consider that action should be 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 Failure of probation officers to understand and remain alert to suicide and self-harm risk in IPP offenders
Wider context from the report “My investigation reveals two relevant concerns:
1. That probation officers need to understand, and be constantly alert to, the risk of suicide/self-harm in IPP offenders. It is clear from Mr Williams’ case, but also from other cases and other evidence, that this cohort often experiences a particular kind of despair. That is fuelled in part by the particular sense of unfairness that they feel about being on an IPP at all, now the sentence has been abolished and all agree that IPP sentences were a terrible idea. The other factor is the absence of hope of ever getting off it.
2. Linked to that second point, it is crucial that probation officers are also fully versed in the processes for suspending parole licence supervision and then cancelling it altogether. One of the real tragedies of Mr Williams’ case is that in 2019 he had been free for ten years, so he should have been referred for licence cancellation. It did not happen, and it is not clear why, but it may have been because no-one was actively looking at him given that his supervision had been suspended. In any event, the referral system did not work and Mr Williams was never referred, at any stage, for cancellation.
Mr Williams was then overtaken by lockdown and related matters in 2020, which pulled the rug on his business and other protective factors, and he then returned to supervision and ultimately recall to prison. Following release in 2022 he was still not referred, and even at the end of that year - which I note was now after the amendments to s.31A of the Crime (Sentences) Act 1997 and the introduction of an entitlement to automatic referral to the Parole Board for cancellation – no referral had been made. By then, of course, Mr Williams might have found cancellation much more difficult. However, it is noteworthy that even with those well publicised changes, which Mr Williams had heard about, his probation officer seemed to be struggling to find out how the process worked (entries in the probation records in December 2022 confirm).
Again, the point is that there is a particular kind of despair among the IPP cohort. The main safeguard is the facility for getting off that, or at least giving these men hope that they may be able to get off it. Mr Williams and his probation officer were struggling to find out how to access even that limited (and automatic) safeguard. It was very shortly after that (within a month or so) that he took his life. The jury was clear that the fact of the IPP caused his state of mind and so caused his death.
It seems to me that these two concerns at least give rise to a training need. There may be more. But I consider that action should be taken.
” Open source report
21 Mar 2024 Alan Richard Miles Davies · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 13 Failure to provide staff with clear information about food and fluid refusal duration and warning signs View source Insufficient consideration of alternative specialist placement View source Failure to provide rest breaks during prolonged night shifts View source Failure to communicate relevant clinical information before transfer View source Insufficient GP capacity to meet demand at HMP Cardiff View source Failure to provide agency staff with sufficient information for informed reception support View source Failure to accompany transfers with Caswell Clinic staff View source Failure to provide clear and understandable discharge information and assessment View source Insufficient assessment of whether needs are too complex for HMP Cardiff View source Failure of healthcare staff to challenge senior staff withdrawal from healthcare assistance View source Failure to devise and implement a clear plan for assessing capacity to refuse food or fluid View source Failure to devise and implement a clear plan for engagement with medical services and assessment of condition View source Lack of a food and fluid refusal policy View source See 10 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
Alan Richard Miles 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
Alan Richard Miles Davies was transferred to HMP Cardiff after 16 days of refusing food and was found collapsed in his cell 10 days later; he later died in hospital. The reported concerns included inadequate communication and handover of information, insufficient care planning and observation, the absence of a food and fluid refusal policy, inadequate staffing, and missed opportunities to escalate his care.
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 staff with clear information about food and fluid refusal duration and warning signs
Wider context from the report “(11) The Nurse, Health care assistant and Custodial manager responsible for Mr Davies on the night of his collapse were not provided with clear information regarding the duration of his fluid and food refusal or the warning signs to consider in the context of the known risk of sudden collapse
” 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 consideration of alternative specialist placement
Wider context from the report “(5) Mr Davies was transferred to HMP Cardiff with the intention that he be transferred again within a short time to HMP Parc. Insufficient consideration was given as to whether Mr Davies’ needs were better met at an alternative specialist institution .
” 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 rest breaks during prolonged night shifts
Wider context from the report “(10) The Nurse and Health care assistant responsible for Mr Davies on the night of his collapse were working an 11.5 hour night shift without rest breaks , which they identified as being overly fatiguing
” 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 relevant clinical information before transfer
Wider context from the report “(1) There was limited communication between the Caswell clinic and HMP Cardiff following the s 117 meeting until Mr Davies’ discharge . In particular, information that Mr Davies had commenced food refusal following the s 117 meeting and that it had not been possible to assess him physically prior to transfer was not clearly communicated to HMP Cardiff before the transfer occurred
” 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 GP capacity to meet demand at HMP Cardiff
Wider context from the report “(9) The number of GPs working in HMP Cardiff was insufficient to meet the demands upon 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 provide agency staff with sufficient information for informed reception support
Wider context from the report “(3) Mr Davies was transferred to prison without being accompanied by a member of Caswell Clinic staff. Agency staff did not have sufficient information to be able to assist prison reception staff in an informed manner
” 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 accompany transfers with Caswell Clinic staff
Wider context from the report “(3) Mr Davies was transferred to prison without being accompanied by a member of Caswell Clinic staff . Agency staff did not have sufficient information to be able to assist prison reception staff in an informed manner
” 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 clear and understandable discharge information and assessment
Wider context from the report “(2) Discharge information and assessment was not provided to HMP Cardiff in a clear and easily understandable format to manage the known risks associated with the transfer of Mr Davies to 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 Insufficient assessment of whether needs are too complex for HMP Cardiff
Wider context from the report “(4) Insufficient consideration was given to whether Mr Davies’ needs were too complex to be met by HMP Cardiff .
” 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 healthcare staff to challenge senior staff withdrawal from healthcare assistance
Wider context from the report “(12) The Health care assistant caring for Mr Davies overnight overheard more senior prison staff stating that they would not return to assist Mr Davies in healthcare , and felt unable to challenge this .
” 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 devise and implement a clear plan for assessing capacity to refuse food or fluid
Wider context from the report “(7) No clear plan for the assessment of Mr Davies’ capacity to refuse food or fluid was devised or implemented at HMP Cardiff
” 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 devise and implement a clear plan for engagement with medical services and assessment of condition
Wider context from the report “(6) No clear plan to promote Mr Davies’ engagement with prison medical services, or the assessment of his mental or physical condition was devised or implemented at HMP Cardiff
” 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 food and fluid refusal policy
Wider context from the report “(8) No food and fluid refusal policy was in place to guide healthcare staff .
” Open source report
22 Feb 2024 Matthew Gregory Price · Prevention of Future Deaths report West Yorkshire (Eastern)
View report summary
Concerns raised 1 Ongoing welfare concerns affecting individuals subject to IPP sentences View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Matthew Gregory Price · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 16 June 2023, Matthew Gregory Price was struck by a train at Cottingley Railway Station and died from multiple injuries; the inquest recorded a short-form conclusion of suicide. The report raised concerns about the impact of ongoing Indeterminate Sentences for Public Protection on the wellbeing of people living in the community, including anxiety about recall and seeking mental-health support.
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 Ongoing welfare concerns affecting individuals subject to IPP sentences
Wider context from the report “It was apparent from the evidence that I heard and read at the inquest that there are serious concerns about the welfare of individuals who remain subject to IPP sentences .
For example, the Independent Monitoring Boards (‘IMB’) completed a report with key findings entitled ‘The impact of IPP sentences on prisoners’ wellbeing’ in May 2023. This report was written following the rejection by the government of the recent Justice Select Committee’s recommendation for a re-sentencing exercise to take place for anyone serving an IPP sentence.
Whilst the key findings of the IMB report are focused upon the impact upon serving prisoners and the prevention of recall, I was deeply concerned about the evidence I heard in relation to the clear impact that the on-going IPP sentence had had on Mr Price. He had served a three year tariff and at the time of his death he had been released back into the community for nearly ten years
Mr Price was anxious about the ever-present potential for recall to prison. Furthermore, he had conveyed in communications to others that he felt that seeking help with his mental health by way of support and medication might count against him when seeking to be successful in discharging the IPP. Whilst Mr Price was engaged with legal support in navigating the review process, the on-going impact of uncertainty of being on an IPP sentence was clearly apparent.
As a consequence of undertaking Mr Price’s inquest, the on-going wellbeing of those serving IPP sentences, be that in prison estate or in the community, is a matter of concern to me as a Coroner .
The Ministry of Justice is fully apprised of the IPP context and whilst matters have been raised by the IMB I am concerned that specific focus upon the welfare of individuals living in the community should be appraised by those who may be able to take appropriate steps to further support an evidently vulnerable section of society,
” Open source report
16 Feb 2024 Sobia Tabasim Khan · Prevention of Future Deaths report Derby and Derbyshire
View report summary
Concerns raised 12 Uncontrolled overseas travel by recently discharged s.41 restricted patients View source Absence of police power to arrest people posing a significant risk of death or serious injury View source Failure to provide clinicians with full risk-assessment reports for discharge decisions View source Inadequate and misleading risk and progress reports for restricted-patient discharge View source Failure to refer high-risk restricted-patient discharge decisions for Mental Health Tribunal scrutiny View source Inadequate recording of risk meetings, decisions and actions View source Over-reliance on self-reporting by a manipulative patient about relationships and risk View source Failure to recall s.41 patients solely posing a significant public risk without mental-health decline View source Lack of available forensic supervision pathways for s.41 restricted patients View source Inadequate clinical record-keeping of material risk information View source Failure to investigate culturally relevant family and community information View source Failure to complete and consider a pre-discharge family assessment View source See 9 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Sobia Tabasim Khan · 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
Sobia Tabasim Khan, aged 37, was murdered shortly after moving from Bradford to Derby to live near a man subject to a restricted hospital order and supervision by multiple agencies. The inquest concluded that her death was an unlawful killing and identified concerns including failures to act on information about the relationship, inadequate supervision and risk assessment, over-reliance on self-reporting, poor record-keeping, and insufficient scrutiny of the man’s discharge and recall.
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 Uncontrolled overseas travel by recently discharged s.41 restricted patients
Wider context from the report “e. Travel overseas for s.41 restricted patients. ████████ was permitted to travel to and from Pakistan freely and to return seemingly as and when he saw fit. Whilst he was outside the jurisdiction there was no way of checking on him, including in terms of his mental health, but also his risk . There were concerns, for example, that he may have been arranging a forced marriage for his niece. He could have entered into a relationship, for all the authorities knew. It also allowed him an opportunity to push and test the boundaries. He was permitted to travel out of the jurisdiction as he pleased, sometimes returning late, sometimes early. By contrast, had he been on licence after serving a custodial sentence, he would in all probability have been prevented from travelling outside the jurisdiction, at least in the early stages. Whilst I acknowledged that there are qualitative differences between a prison sentence and a hospital order, it remains legitimate if not necessary to ensure that those who have recently discharged from a s.41 order are carefully monitored, in the jurisdiction , at least for the first 12 months. This is beneficial not only in terms of monitoring mental health, but also 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 Absence of police power to arrest people posing a significant risk of death or serious injury
Wider context from the report “c. Police power to arrest where there is a reason to believe a person is at risk of death/serious injury. Whilst I was critical of the failure of the police to take measures that were reasonably available to them to investigate the intelligence that had been received that ████████ was in a relationship, the one power that was not available to them was to arrest him . This leaves a significant gap in the powers that are available to the police to protect individuals who are at risk of death/serious injury . Although I cannot say whether the threshold would have been met in Sobhia’s case, such a power could in future cases ensure that it is understood that where an individual poses a significant risk of causing serious harm in relationships, and there is evidence that he is concealing a relationship, he can be arrested.
” 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 clinicians with full risk-assessment reports for discharge decisions
Wider context from the report “f. Clinicians should be provided with full reports when considering discharge. This was a particular concern in relation to the fact that those recommending discharge were not provided with the full Spousal Assault Risk Assessment, but only a summary . Given ████████ risk profile, and the catastrophic consequences that were liable to result from him being pre-emptively discharged, and that discharge was being recommended without recourse to the Tribunal, it was essential that the s.117 meeting was informed by detailed reports which, had they been properly considered, would have indicated a need for circumspection.
” 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 and misleading risk and progress reports for restricted-patient discharge
Wider context from the report “a. Scrutiny of s.41 MHA 1983 cases by the Mental Health Tribunal. In this case ████████ was discharged by the Ministry of Justice (MoJ) following the receipt of reports from Cygnet Hospital which were inadequate and misrepresented the progress he had made and the risk that he posed . Nonetheless there were indicators which should have led the MoJ to question whether this case should have been referred to a Mental Health Tribunal, such as ████████ minimising his culpability for his previous offending. The offences against his former wife were of the utmost gravity, particularly in the context of his behaviour during the marriage that she later disclosed. This indicated a risk of such a level as to make it not only desirable but essential that discharge was not contemplated until there had been close and careful scrutiny by those with expertise in forensic risk assessment. The MoJ Guidance on restricted patients says that “the vast majority” of discharge decisions are made by the Tribunal. In a patient with ████████ risk profile it is difficult to envisage circumstances whereby that should have been displaced.
” 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 refer high-risk restricted-patient discharge decisions for Mental Health Tribunal scrutiny
Wider context from the report “a. Scrutiny of s.41 MHA 1983 cases by the Mental Health Tribunal. In this case ████████ was discharged by the Ministry of Justice (MoJ) following the receipt of reports from Cygnet Hospital which were inadequate and misrepresented the progress he had made and the risk that he posed. Nonetheless there were indicators which should have led the MoJ to question whether this case should have been referred to a Mental Health Tribunal , such as ████████ minimising his culpability for his previous offending. The offences against his former wife were of the utmost gravity, particularly in the context of his behaviour during the marriage that she later disclosed. This indicated a risk of such a level as to make it not only desirable but essential that discharge was not contemplated until there had been close and careful scrutiny by those with expertise in forensic risk assessment . The MoJ Guidance on restricted patients says that “the vast majority” of discharge decisions are made by the Tribunal. In a patient with ████████ risk profile it is difficult to envisage circumstances whereby that should have been displaced.
” 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 recording of risk meetings, decisions and actions
Wider context from the report “h. Record-keeping. This was a thread that ran through the case and applied both to the clinical notes but also the notes of meetings, such as MAPPA, which are necessarily a summary but which did not always include sufficient information to enable those reviewing them to understand what had been discussed and what actions taken . In terms of clinical records, whilst basic, mundane matters such as his sleeping habits and appetite were recorded, much of what mattered was not. The paucity of records and the poverty of their quality meant that ████████ was not aware of the history of manipulation and the other factors which indicated an ample need for reassessment. In terms of the SOTP, whereas there was a conflict of evidence as to why the group programme was not available at Cygnet hospital, the keeping of proper records would have ensured that there was a ready answer if needed. The discharge meetings were poorly recorded, with the spousal assault risk assessment not having featured at all . There were repeated instances of witnesses not being able to remember, understandably, what had happened with respect to certain events. There was no excuse for professional witnesses to be put in this embarrassing position. The MoJ are reliant on what they are told in writing, but given that there is a culture of poor record-keeping, until and unless that record-keeping is improved to an acceptable level, they have to be more pro-active and more prepared to question things.
” 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 Over-reliance on self-reporting by a manipulative patient about relationships and risk
Wider context from the report “g. Over-reliance on self-reporting. This was a theme that ran throughout the inquest and the various agencies involved. This was a case that required a forensic approach throughout, both in hospital and in the community. It was recognised that ████████ was narcissistic and manipulative but he was nonetheless relied upon to provide updates as to his mental health, his travel plans and the reasons for them, and – critically - whether or not he was in a relationship . ████████ risk arose primarily in the context of relationships and he was not somebody that could be relied upon to disclose them. On the contrary, he had shown himself willing and adept at concealing them . This underlined why his self-reporting could not be relied upon and this something that should have featured in his management throughout, and flagged at the point of discharge.
” 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 recall s.41 patients solely posing a significant public risk without mental-health decline
Wider context from the report “d. Ministry of Justice power to recall where a patient poses a significant risk to the public. The MoJ will not generally recall dangerous individuals unless there is a decline in their mental health presentation notwithstanding the fact that s.41 MHA 1983, to which ████████ was subject, is designed to protect the public from serious harm. Whilst there is the possibility of the judge imposing a hybrid order, and that was not considered appropriate in this case, it did not mean that ████████ risk only existed in the context of a decline in his mental health . If an individual subject to a s.41 restriction order poses a significant risk to the public he can be protected if he can be recalled to hospital where further assessment can be 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 Lack of available forensic supervision pathways for s.41 restricted patients
Wider context from the report “b. Ensuring that s.41 restricted patients are supervised under a forensic pathway. In this case no such pathway even existed in the locality . This meant that Mustafa’s supervision was inadequate having regard to the risk that he posed . Such orders are imposed to protect the public from the risk of serious harm. Even where it has been adjudged that any previous offending would not have happened but for a mental disorder, there is still the need for a forensic approach. The risk component must not be overlooked as it was here. Forensic pathways must be available across the country .
” 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 clinical record-keeping of material risk information
Wider context from the report “h. Record-keeping. This was a thread that ran through the case and applied both to the clinical notes but also the notes of meetings, such as MAPPA, which are necessarily a summary but which did not always include sufficient information to enable those reviewing them to understand what had been discussed and what actions taken. In terms of clinical records, whilst basic, mundane matters such as his sleeping habits and appetite were recorded, much of what mattered was not . The paucity of records and the poverty of their quality meant that ████████ was not aware of the history of manipulation and the other factors which indicated an ample need for reassessment. In terms of the SOTP, whereas there was a conflict of evidence as to why the group programme was not available at Cygnet hospital, the keeping of proper records would have ensured that there was a ready answer if needed. The discharge meetings were poorly recorded, with the spousal assault risk assessment not having featured at all. There were repeated instances of witnesses not being able to remember, understandably, what had happened with respect to certain events. There was no excuse for professional witnesses to be put in this embarrassing position. The MoJ are reliant on what they are told in writing, but given that there is a culture of poor record-keeping, until and unless that record-keeping is improved to an acceptable level, they have to be more pro-active and more prepared to question things.
” 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 investigate culturally relevant family and community information
Wider context from the report “i. Familiarisation of professionals with cultural issues. In this case there appears to have been a reluctance to make enquiries with the Mosque and the Islamic Meat Centre, and to be aware of how the family dynamics are impacted by cultural issues . Although it was intended that a family tree would be completed, and this should have been done pre-discharge, ████████ was able to some extent to throw a curtain around his family and thereby promote those working with him from understanding the lengths they were prepared to go to protect him. It was noted that him becoming the Head of the family after his father’s death was significant, but the wider consequences were not properly considered.
” 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 and consider a pre-discharge family assessment
Wider context from the report “i. Familiarisation of professionals with cultural issues. In this case there appears to have been a reluctance to make enquiries with the Mosque and the Islamic Meat Centre, and to be aware of how the family dynamics are impacted by cultural issues. Although it was intended that a family tree would be completed, and this should have been done pre-discharge , ████████ was able to some extent to throw a curtain around his family and thereby promote those working with him from understanding the lengths they were prepared to go to protect him. It was noted that him becoming the Head of the family after his father’s death was significant, but the wider consequences were not properly considered .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue identifying opportunities to enhance guidance and share knowledge with stakeholders.
Verbatim wording from the response “I am confident that the above changes and updated guidance documents, designed to ensure that MHCS are furnished with all relevant information in order to discharge responsibilities under the MHA 1983, and that professionals supervising patients in the community continue to use their professional curiosity has led to an improved overall system. MHCS continue to identify opportunities to enhance our guidance and share knowledge with stakeholders.” Source location Response from Ministry of Justice
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 Update community leave and discharge application forms to require more detail on MAPPA engagement and victims.
Verbatim wording from the response “In March 2022 MHCS updated application forms for community leave and discharge applications requiring increased detail around MAPPA engagement and victims with the aim of improving the quality and completeness of the information submitted to the MHCS.” Source location Response from Ministry of Justice
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 whether changes to recall guidance are necessary.
Verbatim wording from the response “When considering recall, MHCS guidance³ is clear that ‘(T)here is no need for the patient’s mental health to have necessarily deteriorated in order to justify recall’. MHCS can and do recall restricted patients where there is an increased risk to others in order to protect the public. My officials regularly update guidance for those working with restricted patients including the publication of guidance on s42 discharge in March 2022 and shall consider whether any changes to the recall guidance are necessary.” Source location Response from Ministry of Justice
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 Publish learning resources for MAPPA chairs and administrators on risk-focused meetings, agency accountability and risk-management actions.
Verbatim wording from the response “Furthermore, in April 2023 the National MAPPA Team published learning resources for MAPPA Chairs and administrators with the aim of building confidence in ensuring that meetings are focused on risk and that all agencies are clear about their contribution to risk management planning and are accountable for agreed actions.” Source location Response from Ministry of Justice
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 Continue working with partner agencies to support comprehensive supervision of conditionally discharged patients.
Verbatim wording from the response “Also among your concerns was the fact that ████████ had an overall lack of forensic input, namely the lack of a forensic psychiatric evaluation in advance of the request for discharge compounded by there being no community forensic supervision. Although it is not within the legislative powers of the Ministry of Justice to ensure that restricted patients are supervised under a forensic pathway, MHCS continues to work with partner agencies in support of delivering a comprehensive approach to supervision of discharged patients. The Government’s White Paper Reforming the Mental Health Act (January 2021) set out aspirations to strengthen and further develop the role of the social supervisor.” Source location Response from Ministry of Justice
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 a system to identify domestic violence and prompt specific risk questions throughout patients’ movement through hospital.
Verbatim wording from the response “In 2024, MHCS introduced a new system in order to identify cases where domestic violence has taken place, whether as part of the index offence or in the patient’s history. Once identified, the issue of domestic violence will be highlighted to decision makers at all stages of a patient’s movement through the hospital system and prompt them to ask further, specific questions around domestic violence to ensure that this aspect of the risk is properly considered and mitigated.” Source location Response from Ministry of Justice
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Refresh and improve the reporting tool used to update the Secretary of State on restricted patients’ community progress.
Verbatim wording from the response “patients, it covers all aspects of a patient’s discharge into the community. At the same time, the reporting tool that is used to keep the Secretary of State updated with regards to a restricted patient’s progress in the community was also refreshed and improved.” Source location Response from Ministry of Justice
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish guidance for supervising conditionally discharged patients in the community.
Verbatim wording from the response “In July 2023 MHCS published guidance for those supervising conditionally discharged patients in the community¹. The guidance aims to support the supervision and reporting requirements for discharged” Source location Response from Ministry of Justice
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish updated MAPPA meeting guidance with a revised minutes template and aide-memoire to improve recording, follow-up and risk-focused decision-making.
Verbatim wording from the response “Record-keeping was a thread that ran through the case and applied both to the clinical notes but also the notes of meetings, such as MAPPA, which are necessarily a summary but which did not always include sufficient information to enable those reviewing them to understand what had been discussed and what actions taken. The National MAPPA Team in the Ministry of Justice has sought to improve the quality of MAPPA meetings and the recording of decisions. Specifically, in May 2022 updated Statutory Guidance was published on the conduct and recording of MAPPA meetings, including attendance, a clear focus on decisions relating to risk assessment and management, and that actions are clearly recorded and followed up. The Guidance is supported by a revised minutes template and an aide-memoire for MAPPA Chairs.” Source location Response from Ministry of Justice
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 A blanket ban on overseas travel cannot be imposed because the Mental Health Act 1983 provides no mechanism for doing so.
Verbatim wording from the response “One of your concerns centred on the fact that ████████ was allowed to travel to Pakistan soon after his discharge into the community. Under the MHA 1983, there is no statutory bar to overseas travel for conditionally discharged patients and no mechanism for the Secretary of State to impose a blanket ban on all overseas travel. However, guidance published in July 2023 underlines the following expectations:” Source location Response from Ministry of Justice
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 The discharge process does not require changes, given the independent scrutiny of its legislative provisions.
Verbatim wording from the response “You suggested it would have been more appropriate for the discharge decision to have been put before a Tribunal instead of it being taken by the MHCS on behalf of the Secretary of State. Parliament entrusted to the Secretary of State a power to discharge restricted patients, and unlike the Tribunal, which must reach a decision on discharge entirely on the statutory criteria in section 73 of the Act, the Secretary of State has a broad discretion to order discharge where deemed safe to do so. The MHA 1983 has been subject to intense public scrutiny since 2017, when the then Prime Minister, Theresa May, commissioned an Independent Review of the Act. In response, the Government published a White Paper and public consultation in 2021. The Draft Mental Health Bill (MH Bill) was published in June 2022 and made subject to Pre-Legislative Scrutiny.” Source location Response from Ministry of Justice
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 Ensuring restricted patients are supervised under a forensic pathway is outside the Ministry’s legislative powers.
Verbatim wording from the response “Also among your concerns was the fact that ████████ had an overall lack of forensic input, namely the lack of a forensic psychiatric evaluation in advance of the request for discharge compounded by there being no community forensic supervision. Although it is not within the legislative powers of the Ministry of Justice to ensure that restricted patients are supervised under a forensic pathway, MHCS continues to work with partner agencies in support of delivering a comprehensive approach to supervision of discharged patients. The Government’s White Paper Reforming the Mental Health Act (January 2021) set out aspirations to strengthen and further develop the role of the social supervisor.” Source location Response from Ministry of Justice
Open published response
×
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 Day-to-day supervision of conditionally discharged patients is the responsibility of community care teams.
Verbatim wording from the response “The Mental Health Casework Section (MHCS) in HMPPS exercises the Secretary of State’s statutory powers under the Mental Health Act 1983 (MHA 1983), whilst the day to day supervision of conditionally discharged patients is the responsibility of the care team in the community.” Source location Response from Ministry of Justice
Open published response
6 Feb 2024 Mark PRYOR · Prevention of Future Deaths report Derby and Derbyshire
View report summary
Concerns raised 1 Lack of sufficient training for health care professionals working in police custody suites 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
Mark PRYOR · 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
Mark Pryor died at the emergency department of Royal Derby Hospital on 5 September 2020 after suffering an alcohol-withdrawal-related seizure and cardiorespiratory arrest while in police custody. The inquest jury found deficiencies in the health care professionals’ assessment and treatment of his alcohol withdrawal that probably made more than a minimal contribution to his death. The report raises concerns that health care professionals may not receive sufficient training to practise effectively and safely in police custody suites.
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 sufficient training for health care professionals working in police custody suites
Wider context from the report “I am concerned that Health Care Professionals (HCPs) may not be receiving sufficient and adequate training to enable them to practice effectively or safely in police custody suites. This is based on the evidence and findings in Mr Pryor’s inquest and my understanding that the training provided by HCRG may be very similar to that given by other providers of HCP police custody services nationally.
Clinical assessment and treatment is provided to police custody detainees by HCPs with the support of an on-call doctor. Typically there will be one HCP per shift. Nationally, HCP services are provided by a number of independent providers under contract to individual police forces. Professionals eligible to be recruited as HCPs (as taken from HCRG personal specification) are registered nurses (general or mental health), or paramedics with a minimum of two years post-qualification with NMC or HCPC registration and ‘nursing experience in the following: A&E, ITU, EAU, SAU, Nurse Practitioner, Practice Nurse, EAU, SAU (other nursing backgrounds will be considered)'.
Current training provided to newly appointed HCPs (by HCRG) consists of shadowing shifts with an experienced HCP, potentially for up to six or eight shifts; a two-day induction course; a medication related course of less than a day which includes a pass or fail test. There is also formal supervision and a three-month probationary period.
The two-day induction course covers the following topics: -
Day 1
Overview of the role of HCPs in custody; Consent, confidentiality and ethics – covering topics including the relevant laws, regulations and regulatory issues, the importance and limitations of concept, assessing capacity, nature of the HCPs dual responsibility and how it affects disclosure of sensitive information. and importance of record keeping; Fitness to detain – covering topics including the need to assess detainees for injuries, illness, and drug and alcohol problems, formulating a care plan in custody to manage risk and identifying those who are not fit to detain who may need alternative support; Fitness to interview / charge/ transfer / release – covering topics including a recap on assessing capacity and assessing, safeguards to prevent the risk of involuntary/false confessions, overview of illnesses that might be worsened by interview and facts to consider when assessing detainees’ fitness to release; Drugs and alcohol is police custody – covering topics including examination features of alcohol and/ or opiate intoxication, examination features of alcohol or opiate withdrawal, key assessment details in the detainee with alcohol dependence, treatment of alcohol / opiate withdrawal in police custody; Mental health in custody - covering topics including the relevant sections of the Mental Health Act, the overlap of learning difficulties with mental health in police custody, the role of liaison and diversion (L&D) teams and the approved mental health professional (AMHP) and when to refer to specialist services; Mental state examination (MSE) – covering topics including purpose of MSE, format of MSE, communicating MSE findings and risk assessments.
Day 2
Forensic science and samples – covering topics including understanding Locard’s Principle, which offences may trigger sample requests, taking non intimate and intimate samples and relevant procedural steps; Traffic Medicine – covering relevant procedures under the Road Traffic Act; Restraint, TASER and irritant sprays – covering an overview of different types of restraint and when a detainee may need hospital following restraint; Documentation of injury – covering how to take history for injuries, how to describe, document and classify injuries; Statement writing – covering topics including overview on preparing a witness statement, format of a witness statement and information required to complete a statement and importance of good clinical notation on the assessment forms provided in custody.
I have reproduced the summary of training, which was given in evidence at the inquest, to illustrate that there are obviously a very extensive number of topics which are listed to be covered.
I find it difficult to see that necessary training can be given within the specified time to equip a paramedic or nurse who is fresh to the custody setting to practice effectively and safely. The inquest heard evidence from the more experienced HCP that when she started, with a different provider some eight years prior, she had six weeks classroom-based training before she commenced full duties as an HCP. The injunction also heard that The Faculty of Forensic & Legal Medicine recommends a five-day induction course for HCPs.
” Open source report
21 Dec 2023 Wyndham Richard Thomas · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 4 Unavailability of in-cell ligature point maps to staff View source Lack of in-cell ligature point risk assessments View source Unavailability of designated Safer Cells View source Lack of a mandatory requirement for prisons to provide access to Safer Cells View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Wyndham Richard Thomas · 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
Wyndham Richard Thomas was a serving prisoner who was found unconscious in his cell after ligating on 4 November 2018 and died in hospital on 6 November 2018. The substantive concerns were the absence of in-cell ligature-point risk assessments and maps, and the lack of designated safer cells at HMP Nottingham, which reduced opportunities to mitigate the risk of self-harm and death by ligature asphyxiation.
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 in-cell ligature point maps to staff
Wider context from the report “1. There is a lack of local and national system of in-cell ligature point risk assessments, and no ligature point maps available to staff .
The Prison Staff caring for Wyndham were not aware of the location of known ligature points within the cell . This meant that suspicion was not drawn when Wyndham was seen positioned in an area which had access to a ligature point.
” 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 in-cell ligature point risk assessments
Wider context from the report “1. There is a lack of local and national system of in-cell ligature point risk assessments , and no ligature point maps available to staff.
The Prison Staff caring for Wyndham were not aware of the location of known ligature points within the cell. This meant that suspicion was not drawn when Wyndham was seen positioned in an area which had access to a ligature point.
” 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 designated Safer Cells
Wider context from the report “2. There is no mandatory requirement for a HMP Prison to have access to a Safer Cell (one with reduced ligature points) available to staff.
HMP Nottingham does not have designated Safer Cells , including on the Care and Support Unit , where prisoners posing a high risk of harm by ligation may be sent for their 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 Lack of a mandatory requirement for prisons to provide access to Safer Cells
Wider context from the report “2. There is no mandatory requirement for a HMP Prison to have access to a Safer Cell (one with reduced ligature points) available to staff .
HMP Nottingham does not have designated Safer Cells, including on the Care and Support Unit, where prisoners posing a high risk of harm by ligation may be sent for their own safety.
” Open source report
Concerns raised 5 Failure to carry out scheduled ACCT observations View source Failure to maintain accurate and complete ACCT observation records View source Lack of a collective inter-agency response to learning lessons View source Failure to ensure transfer for psychiatric treatment where required View source Failure to ensure correct levels of observation up to constant watch 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
Martin Samuel WILLIS · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Martin Samuel Willis was a serving prisoner at HMP Stoke Heath when he was found hanging in his cell on 15 September 2022. He was on the suicide and self-harm prevention scheme, but concerns included failures in observation recording and supervision, uncertainty about the appropriate observation level and possible transfer for mental health treatment, and the need for a collective review of the care provided.
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 carry out scheduled ACCT observations
Wider context from the report “1. The ACCT procedure was not properly implemented, complied with or supervised . A scheduled observation at 8 am did not take place and a false entry was entered at 7:30 am and later deleted. The last correct entry was at 7 am with earlier omissions.
” 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 accurate and complete ACCT observation records
Wider context from the report “1. The ACCT procedure was not properly implemented, complied with or supervised . A scheduled observation at 8 am did not take place and a false entry was entered at 7:30 am and later deleted . The last correct entry was at 7 am with earlier omissions .
” 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 collective inter-agency response to learning lessons
Wider context from the report “4. Whilst the prison service and the mental health providers have reviewed the circumstances of Mr Willis’s death, I am concerned that there should be a collective and not individual response to ensure that all lessons can be learned . I therefore recommend that there be an inter-agency review between the prison service and mental health services as to the mental health care provided to the late Mr Willis including the evidence at the inquest and the jury’s findings. In so doing, I do not purport to suggest what the outcome of the review should be.
” 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 transfer for psychiatric treatment where required
Wider context from the report “3. Overriding issues remain as to whether or not the late Mr Willis was on the correct levels of observation up to constant watch and whether he should have been transferred to an psychiatric grounds for treatment at another prison establishment with a hospital wing .
” 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 correct levels of observation up to constant watch
Wider context from the report “3. Overriding issues remain as to whether or not the late Mr Willis was on the correct levels of observation up to constant watch and whether he should have been transferred to an psychiatric grounds for treatment at another prison establishment with a hospital wing.
” Open source report
5 Dec 2023 Samuel Lewis Jones · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 4 Lack of flagging of and access to key dates affecting prisoners’ safety View source Lack of national guidance for managing in-possession medication View source Failure of NOMIS information accessibility to support risk assessments View source Lack of national guidance for managing safety risks associated with key dates View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Samuel Lewis Jones · 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 Lewis Jones died on 30 April 2021 after suspending himself by a ligature in his cell at HMP Portland. The concerns identified included the lack of systems and national guidance for recording and flagging significant dates, difficulties accessing key information in prison records, and insufficient national guidance on managing medication held in prisoners’ possession.
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 flagging of and access to key dates affecting prisoners’ safety
Wider context from the report “i. The lack of flagging of, and access to, key dates which may have an impact on prisoners’ 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 Lack of national guidance for managing in-possession medication
Wider context from the report “iv. The lack of national guidance around the operation of in possession medication in prisons either by HMPPS or NHS England to ensure prisoners do not stockpile or retain medication when they have stopped using it .
” 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 NOMIS information accessibility to support risk assessments
Wider context from the report “iii. The accessibility of information recorded on NOMIS and the potential to miss key information which could impact on risk 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 Lack of national guidance for managing safety risks associated with key dates
Wider context from the report “ii. The lack of national Prison Service or NHS guidance on how to manage key dates where risks to the safety of the prisoner may be increased , such as a bereavement or traumatic incident or any other key dates.
” Open source report
×
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 Operational concerns should be addressed by HMPPS Director General of Operations, rather than by the Minister.
Verbatim wording from the response “The concerns you have raised within your report are operational issues and it is therefore appropriate for ████████, DG Operations, HM Prison and Probation Service (HMPPS), to respond to them. I have seen the response from ████████ and I endorse the content of it, which sets out the action being taken by HMPPS to address your concerns.” Source location Response from Ministry of Justice
Open published response
7 Nov 2023 Terri Liz Harris and 3 others · Prevention of Future Deaths report Derby and Derbyshire
View report summary
Concerns raised 10 Insufficient or absent probation domestic abuse and child safeguarding checks View source Insufficient or untimely domestic abuse and child safeguarding training for probation practitioners View source Failure to ensure that PSR reports accurately evidence completed checks View source Failure to report potentially risk-indicating offender comments from electronic monitoring View source Failure to maintain accurate, prominent and readily updateable offender risk records View source Failure to complete domestic abuse and child safeguarding checks before proposing curfew conditions View source Uncertainty about contacting homeowners or lead tenants to assess curfew-address suitability View source Failure to promptly notify the Probation Service of missed substance misuse appointments View source Failure to review offender records at critical risk-assessment points View source Failure to conduct child safeguarding checks where offenders will live with or access children View source See 7 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
Terri Liz Harris and 3 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
Terri Liz Harris, her children John-Paul Bennett and Lacey Bennett, and their friend Connie Gent were discovered deceased at Terri’s home on 19 September 2021. They had been murdered by Terri’s partner, Damien Bendall, who inflicted severe head injuries on all four; the report also states that he raped Lacey. The deaths were contributed to by acts and omissions in offender supervision and electronic monitoring, including concerns about risk-recording, domestic abuse and child-safeguarding checks, reporting of threats, and notification of missed treatment appointments.
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 Insufficient or absent probation domestic abuse and child safeguarding checks
Wider context from the report “The inquests identified that DA and SG checks were either insufficient or wholly lacking at various stages of Damien Bendall’s offender management. The current evidence is that DA and SG checks remain generally insufficient or are not being done with consequent on-going risks to children and women.
Insufficient or absent PS DA and SG checks has been a theme of HM Inspectorate of Probation reports and reviews for at least the last 5 years. On HM Inspectorate of Probation case sampling to determine whether domestic abuse and child safeguarding enquiries were being undertaken when indicated, the HM Inspectorate of Probation Annual Report for 2022/2023 states at page 38:-
where inspectors judged that these enquiries needed to be made by the probation practitioner, child safeguarding enquiries were carried out in 55 per cent of cases, domestic abuse enquiries were only carried out in 49 per cent of cases and risk of harm was only properly addressed in 39 per cent .
” 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 or untimely domestic abuse and child safeguarding training for probation practitioners
Wider context from the report “A significant issue in the inquests was the fact that the very inexperienced staff who were (wrongly) allocated Damien Bendall’s case on transfer to the East Midlands PS region had insufficient DA and SG training. The PS states it has introduced more robust DA and SG training, but it is unclear whether PS practitioners are receiving this before cases are allocated to them to manage .
” 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 that PSR reports accurately evidence completed checks
Wider context from the report “There is no evidence that DA and SG checks were made by the PS practitioner in respect of Damien Bendall’s PSR report. Via the report the court was informed that checks had been conducted. The PS practitioner put forward a curfew provision as appropriate and the report was written in such a way to indicate that the report writer had checked the suitability of the curfew address, when she had not in fact done so . Had the court not been misled it is unlikely that the court’s disposal would have included a curfew requirement.
The inquests heard that PSRs written by the same PS practitioner, reviewed before her submission of Damien Bendall’s PSR, and reports reviewed after the murders, also lacked evidence of DA and SG checks having been made even though they were stated to have been done in the reports .
” 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 potentially risk-indicating offender comments from electronic monitoring
Wider context from the report “Damien Bendall made the comment “If this relationship goes bad I’ll murder my girlfriend and the children” to the EMS field operative who fitted his tag and monitoring equipment but this was not reported back by the field operative to her manager nor to the PS. EMS has stated that it has introduced relevant training but the inquest heard evidence from the field operative that comments made by offenders which can be interpreted as potentially posing risk are currently routinely not being reported back by EMS field operatives .
The inquests examined the relevant contract terms between the Ministry of Justice and Capita (EMS) relating to reporting concerns and there did appear to be lack of clarity on reporting mechanisms and issues to report .
” 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 accurate, prominent and readily updateable offender risk records
Wider context from the report “The inquests identified that very concerning information regarding Damien Bendall was made known to the PS (including violent assault and injury of a partner, and an incident of possible child sexual abuse) but was not recorded clearly or prominently for subsequent PS practitioners to read and evaluate in risk assessment and decision-making , and indeed was not read at key and critical points. Although this was in part due to the recording made by individual PS practitioners it was also the result of confusing proformas (e.g. the OASys misleading drop-down boxes and the open and closed sections), imprecise arrangements and expectations of how and where such information should be recorded, and where checks should be directed to and made when the records needed to be reviewed. The inquests were informed of current PS expectations for recording offender risk information and assessments, but I remain very unsure that there are clear and efficient recording arrangements and systems to ensure that risk information is accurate, prominent, easily seen, and easily updateable by PS practitioners .
” 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 domestic abuse and child safeguarding checks before proposing curfew conditions
Wider context from the report “The PS is not currently conducting SG checks in all cases where an offender will live with or have access to children.
The PS has mandated that in all cases where a curfew condition is proposed to the court in a pre-sentence report (PSR) DA and SG checks will be conducted prior to the proposal and submission of the PSR: this is not being done in all cases. I am also unclear whether contact to the address homeowner/lead tenant for a potential curfew condition to discuss the suitability of a curfew condition is being undertaken in all cases.
” 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 Uncertainty about contacting homeowners or lead tenants to assess curfew-address suitability
Wider context from the report “The PS is not currently conducting SG checks in all cases where an offender will live with or have access to children.
The PS has mandated that in all cases where a curfew condition is proposed to the court in a pre-sentence report (PSR) DA and SG checks will be conducted prior to the proposal and submission of the PSR: this is not being done in all cases. I am also unclear whether contact to the address homeowner/lead tenant for a potential curfew condition to discuss the suitability of a curfew condition is being undertaken in all cases.
” 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 promptly notify the Probation Service of missed substance misuse appointments
Wider context from the report “The precise number is not clear on the records, but he missed 4 or 5 appointments with the service between 21 July and his first attended appointment on 17 September 2021, but the required proforma attendance/non-attendance forms were not sent by the substance misuse service to notify the PS .
Such non-attendance is non-compliance with the court-imposed alcohol treatment requirement and should be considered by the PS practitioner for referral back to the court as a breach of the court order. Clearly it is vital that non-attendance is formally and quickly notified to the PS practitioner especially where there is a relationship between use of substances and violent offending.
” 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 review offender records at critical risk-assessment points
Wider context from the report “The inquests identified that very concerning information regarding Damien Bendall was made known to the PS (including violent assault and injury of a partner, and an incident of possible child sexual abuse) but was not recorded clearly or prominently for subsequent PS practitioners to read and evaluate in risk assessment and decision-making, and indeed was not read at key and critical points . Although this was in part due to the recording made by individual PS practitioners it was also the result of confusing proformas (e.g. the OASys misleading drop-down boxes and the open and closed sections), imprecise arrangements and expectations of how and where such information should be recorded, and where checks should be directed to and made when the records needed to be reviewed . The inquests were informed of current PS expectations for recording offender risk information and assessments, but I remain very unsure that there are clear and efficient recording arrangements and systems to ensure that risk information is accurate, prominent, easily seen, and easily updateable by PS practitioners.
” 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 child safeguarding checks where offenders will live with or access children
Wider context from the report “The PS is not currently conducting SG checks in all cases where an offender will live with or have access to children.
The PS has mandated that in all cases where a curfew condition is proposed to the court in a pre-sentence report (PSR) DA and SG checks will be conducted prior to the proposal and submission of the PSR: this is not being done in all cases. I am also unclear whether contact to the address homeowner/lead tenant for a potential curfew condition to discuss the suitability of a curfew condition is being undertaken in all cases.
” Open source report
12 Oct 2023 Mr Jonathan Michael McCarthy · Prevention of Future Deaths report Northamptonshire
View report summary
Concerns raised 4 Failure to determine the clinical importance and urgency of pre-existing community hospital appointments in light of security issues View source Failure to verify prisoners’ pre-existing community hospital appointments View source Failure to determine medical hold View source Failure to assess fitness to transfer 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
Mr Jonathan Michael McCarthy · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mr Jonathan Michael McCarthy died on 12 August 2018 at University Hospital Coventry and Warwickshire from a cardiac arrhythmia associated with scarring of the heart, while at HMP Onley. Concerns included failures to verify and assess the clinical importance of pre-existing community hospital appointments, the impact of security issues on those appointments, and whether he was fit to transfer or should have been placed on medical hold.
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 determine the clinical importance and urgency of pre-existing community hospital appointments in light of security issues
Wider context from the report “Upon Mr McCarthy’s arrival at HMP Altcourse on 5 June 2017, it is recorded that he had an outstanding hospital appointment. There was no evidence that HMP Altcourse took any steps to verify this appointment.
Mr McCarthy was transferred to HMP Thameside on 7 May 2018. It is recorded that he had an appointment to see the cardiologist at Whittington Hospital on 13 June 2018. There was no evidence that HMP Thameside took any steps to verify this appointment. He was transferred from the prison on the next day, 14th June 2018.
It was suggested in evidence that HMP Thameside automatically re-arrange all community medical appointments for security reasons. It was clarified that the prison would only try to get a new appointment if there was a specific security concern.
There was also no evidence that Mr McCarthy had a fitness to transfer assessment at either HMP Altcourse or HMP Thameside.
1. verifying a prisoner’s pre-existing community hospital appointments.
2. determining the clinical importance/urgency of pre-existing community hospital appointments and the impact of security issues upon this assessment.
3. assessing fitness to transfer and determining medical hold.
” 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 prisoners’ pre-existing community hospital appointments
Wider context from the report “Upon Mr McCarthy’s arrival at HMP Altcourse on 5 June 2017, it is recorded that he had an outstanding hospital appointment. There was no evidence that HMP Altcourse took any steps to verify this appointment.
Mr McCarthy was transferred to HMP Thameside on 7 May 2018. It is recorded that he had an appointment to see the cardiologist at Whittington Hospital on 13 June 2018. There was no evidence that HMP Thameside took any steps to verify this appointment. He was transferred from the prison on the next day, 14th June 2018.
It was suggested in evidence that HMP Thameside automatically re-arrange all community medical appointments for security reasons. It was clarified that the prison would only try to get a new appointment if there was a specific security concern.
There was also no evidence that Mr McCarthy had a fitness to transfer assessment at either HMP Altcourse or HMP Thameside.
1. verifying a prisoner’s pre-existing community hospital appointments.
2. determining the clinical importance/urgency of pre-existing community hospital appointments and the impact of security issues upon this assessment.
3. assessing fitness to transfer and determining medical hold.
” 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 determine medical hold
Wider context from the report “Upon Mr McCarthy’s arrival at HMP Altcourse on 5 June 2017, it is recorded that he had an outstanding hospital appointment. There was no evidence that HMP Altcourse took any steps to verify this appointment.
Mr McCarthy was transferred to HMP Thameside on 7 May 2018. It is recorded that he had an appointment to see the cardiologist at Whittington Hospital on 13 June 2018. There was no evidence that HMP Thameside took any steps to verify this appointment. He was transferred from the prison on the next day, 14th June 2018.
It was suggested in evidence that HMP Thameside automatically re-arrange all community medical appointments for security reasons. It was clarified that the prison would only try to get a new appointment if there was a specific security concern.
There was also no evidence that Mr McCarthy had a fitness to transfer assessment at either HMP Altcourse or HMP Thameside.
1. verifying a prisoner’s pre-existing community hospital appointments.
2. determining the clinical importance/urgency of pre-existing community hospital appointments and the impact of security issues upon this assessment.
3. assessing fitness to transfer and determining medical hold.
” 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 assess fitness to transfer
Wider context from the report “Upon Mr McCarthy’s arrival at HMP Altcourse on 5 June 2017, it is recorded that he had an outstanding hospital appointment. There was no evidence that HMP Altcourse took any steps to verify this appointment.
Mr McCarthy was transferred to HMP Thameside on 7 May 2018. It is recorded that he had an appointment to see the cardiologist at Whittington Hospital on 13 June 2018. There was no evidence that HMP Thameside took any steps to verify this appointment. He was transferred from the prison on the next day, 14th June 2018.
It was suggested in evidence that HMP Thameside automatically re-arrange all community medical appointments for security reasons. It was clarified that the prison would only try to get a new appointment if there was a specific security concern.
There was also no evidence that Mr McCarthy had a fitness to transfer assessment at either HMP Altcourse or HMP Thameside.
1. verifying a prisoner’s pre-existing community hospital appointments.
2. determining the clinical importance/urgency of pre-existing community hospital appointments and the impact of security issues upon this assessment.
3. assessing fitness to transfer and determining medical hold.
” Open source report
3 Oct 2023 Manoel Messias Santos · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 10 Failure to provide timely notification of immigration detention before release View source Delays and failures by the SSHD in progressing FNO cases and obtaining required information View source Delays by probation in allocating community offender managers and providing up-to-date OASYS reports View source Absence of a prison offender manager specialist model for FNO immigration liaison View source Failure to facilitate and signpost access to immigration legal advice View source Failure of communication between immigration and sentence-planning agencies View source Persistent misunderstanding of the policy governing OSG officers opening cell doors at night View source Insufficient communication of entitlement to free immigration legal advice View source Lack of clear systems for obtaining medical information View source Failure to disseminate and action important learning points View source See 7 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Manoel Messias Santos · 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
Manoel Messias Santos, a Brazilian national detained in prison and facing immigration detention and possible deportation, was found hanging in his cell in the early hours of 2 November 2020 and was declared dead at 3.30am. The jury found that his understanding of his immigration position made a material contribution to his death and identified failures in notifying him about the IS91 notice and communicating his immigration position. The report also raised concerns about delays in notification and case handling, access to legal advice, communication between agencies, dissemination of learning, and staff understanding of the policy on opening cell doors at night.
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 timely notification of immigration detention before release
Wider context from the report “2. The timing of the notification to Mr Santos by the SSHD that he was not to be released at the end of his custodial sentence but was to be held on immigration detention pending a decision on deportation. The SSHD target for notification is 30 days prior to release. In this case it was 8 days late. I heard PFD evidence that this 30-day target is not met in 40% of cases and that 83% of cases are notified within 7 days of the end of the sentence . I am concerned at the potential uncertainty and distress caused to Foreign National Offenders (“FNOs”) by notification at this stage.
” 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 and failures by the SSHD in progressing FNO cases and obtaining required information
Wider context from the report “8. I am concerned at the potential impact of delays/failure to obtain information in other cases. In Mr Santos’ case there were delays by probation in allocating a community offender manager and providing an up-to-date OASYS report. There were also delays by the SSHD progressing Mr Santos’ case , including issue of the Stage 2 letter , failure to obtain medical records and delay in requesting the OASYS report .
9. I am encouraged that there is now a centralised system (and form) for the SSHD to request OASYS reports from probation although it is not clear the extent to which requests are going through this system. Consent to obtain medical information is sought from FNOs at an induction meeting by Immigration Prison Teams (“IPTs”). Further IPT officers attend prisons and play a key role in obtaining this type of information. However it is not clear what systems are in place to facilitate the obtaining of medical information.
” 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 by probation in allocating community offender managers and providing up-to-date OASYS reports
Wider context from the report “8. I am concerned at the potential impact of delays/failure to obtain information in other cases. In Mr Santos’ case there were delays by probation in allocating a community offender manager and providing an up-to-date OASYS report . There were also delays by the SSHD progressing Mr Santos’ case, including issue of the Stage 2 letter, failure to obtain medical records and delay in requesting the OASYS report.
9. I am encouraged that there is now a centralised system (and form) for the SSHD to request OASYS reports from probation although it is not clear the extent to which requests are going through this system. Consent to obtain medical information is sought from FNOs at an induction meeting by Immigration Prison Teams (“IPTs”). Further IPT officers attend prisons and play a key role in obtaining this type of information. However it is not clear what systems are in place to facilitate the obtaining of medical information.
” 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 Absence of a prison offender manager specialist model for FNO immigration liaison
Wider context from the report “6. Communication issues between the agencies dealing with immigration and sentence planning may lead to confusion and uncertainty for FNOs.
7. I appreciate that any legal advice for FNOs should be from a legal adviser. I am encouraged that the probation service (who employ community offender managers) is seeking to develop a cohort of probation officers specialising in FNOs and immigration. There are now 201 SPOCs across 12 regions and a hub lead developing this model and leading engagement with the SSHD. There is no such model in the prison in respect of “prison offender managers” who also liaise with the SSHD about FNOs.
” 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 facilitate and signpost access to immigration legal advice
Wider context from the report “4. I am concerned as to how access to legal advice is facilitated and signposted.
5. In PFD evidence, I was informed that FNOs (in a similar position to Mr Santos) are now entitled to 30 minutes of free legal advice following a High Court decision in February 2021. In HMP Belmarsh, this entitlement is displayed on a notice in each Houseblock. I am concerned that displaying a notice is insufficient to draw this entitlement to the attention of FNOs. I do not know if this is a wider issue in other prisons. Understanding of immigration status, including appeal and bail procedures and is complex. Access to legal advice is vital to prevent confusion.
” 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 communication between immigration and sentence-planning agencies
Wider context from the report “6. Communication issues between the agencies dealing with immigration and sentence planning may lead to confusion and uncertainty for FNOs.
7. I appreciate that any legal advice for FNOs should be from a legal adviser. I am encouraged that the probation service (who employ community offender managers) is seeking to develop a cohort of probation officers specialising in FNOs and immigration. There are now 201 SPOCs across 12 regions and a hub lead developing this model and leading engagement with the SSHD. There is no such model in the prison in respect of “prison offender managers” who also liaise with the SSHD about FNOs.
” 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 Persistent misunderstanding of the policy governing OSG officers opening cell doors at night
Wider context from the report “13. In evidence there was a continued misunderstanding that the policy did not apply to Operational Support Grade (OSG) officers and it was understood that they should never open cell doors at night . This was despite the PPO report dated December 2021 (at paragraph 73) requesting this be addressed.
14. The prison stated in PFD evidence that all staff will be instructed as to the policy in terms of opening cell doors at night (which requires a dynamic risk assessment).
15. I remain concerned that this appears to be a longstanding belief held by experienced officers .
” 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 communication of entitlement to free immigration legal advice
Wider context from the report “4. I am concerned as to how access to legal advice is facilitated and signposted.
5. In PFD evidence, I was informed that FNOs (in a similar position to Mr Santos) are now entitled to 30 minutes of free legal advice following a High Court decision in February 2021. In HMP Belmarsh, this entitlement is displayed on a notice in each Houseblock. I am concerned that displaying a notice is insufficient to draw this entitlement to the attention of FNOs. I do not know if this is a wider issue in other prisons. Understanding of immigration status, including appeal and bail procedures and is complex. Access to legal advice is vital to prevent confusion.
” 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 clear systems for obtaining medical information
Wider context from the report “8. I am concerned at the potential impact of delays/failure to obtain information in other cases. In Mr Santos’ case there were delays by probation in allocating a community offender manager and providing an up-to-date OASYS report. There were also delays by the SSHD progressing Mr Santos’ case, including issue of the Stage 2 letter, failure to obtain medical records and delay in requesting the OASYS report.
9. I am encouraged that there is now a centralised system (and form) for the SSHD to request OASYS reports from probation although it is not clear the extent to which requests are going through this system. Consent to obtain medical information is sought from FNOs at an induction meeting by Immigration Prison Teams (“IPTs”). Further IPT officers attend prisons and play a key role in obtaining this type of information. However it is not clear what systems are in place to facilitate the obtaining of medical information.
” 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 disseminate and action important learning points
Wider context from the report “10. The SSHD disclosed an Internal report into Mr Santos’ case midway through the Inquest, which was not on his Home Office file. The lawyers representing the SSHD were unaware of this report. The head of FNO Returns Command only became aware of it the preceding week and understood it had been disclosed.
11. The report detailed delays and issues in Mr Santos’ case and the SSHD then made formal admissions of the relevant (non-causative) failures which where recorded by the jury in the Record of Inquest at my direction.
12. This report was dated February 2021 and listed action points for the relevant department. Although I am told that these are now being addressed, I am concerned that important learning points (which could prevent future deaths) were not disseminated and actioned as they should have been.
” Open source report
8 Sep 2023 KRISTOPHER COREY JAMIE LEE TILBURY · Prevention of Future Deaths report Hertfordshire
View report summary
Concerns raised 4 Weak and unembedded illicit drug supply reduction work View source Failure to complete required intelligence-led searches View source Widespread availability of drugs and alcohol in the prison View source Failure to complete suspicion drug tests 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
KRISTOPHER COREY JAMIE LEE TILBURY · 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
Kristopher Corey Jamie Lee Tilbury died in his prison cell at HMP The Mount after smoking a synthetic cannabinoid and consuming alcohol, causing respiratory depression. The report raised concerns that illicit drugs and alcohol remained widely available at the prison, including on a wing for prisoners with substance misuse issues, creating a significant risk of future deaths.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Weak and unembedded illicit drug supply reduction work
Wider context from the report “(1) In May 2018 (16 months before Mr Tilbury’s death) HMP the Mount was subject to an inspection by HM Inspectorate for Prisons. The Inspectors found that levels of violence were comparatively high and mostly related to drugs and debt. They found that less than half of required intelligence led searches were completed and most suspicion drugs tests were missed. They reported that mandatory drug testing indicated that nearly a third of prisoners were using illicit drugs, and that this undermined the prison’s ability to remain safe. The inspectors found that drug supply reduction work was weak and not embedded in the wider strategy , and that half of the prisoners said it was easy to access illicit drugs. The proportion of positive mandatory drug tests, including for psychoactive substances (████████), was high at 32%.
(2) In the report of the Independent Monitoring Board for the year to February 2019 it was noted that drugs were widely available in the prison.
(3) Mr Tilbury died on 24th September 2019 and was found dead in his cell. The medical cause of his death was established by the pathologist at the inquest as respiratory depression caused by the combined use synthetic cannabinoids and alcohol.
(4) The Prisons and Probation Ombudsman carried out an independent investigation into the death of Mr Tilbury on 24th September 2019 at the Mount. The report was produced, as a result of this investigation, in March 2020. The report concluded that it was extremely troubling that Mr Tilbury was able to access and use illicit substances, including Psychoactive Substances, with apparent ease at The Mount, particularly as he lived on a wing for prisoners with substance misuse issues. The report concluded that much more needed to be done to tackle the issue of illicit substances at the prison , and the Governor should ensure that key drug issues at the Mount are identified and that the prison’s local drug strategy be appropriately revised to address them.
(5) Since the death of Mr Tilbury, and the Prisons and Probation Ombudsman’s, report four other prisoners have died at HMP The Mount as a result of taking ████████, namely:
a. Prisoner X ████████ – died on 14th July 2022
b. Prisoner Y ████████ – died on 25th July 2022
c. Prisoner Z ████████ – died on 6th January 2023
d. Prisoner W ████████ – died on 26th January 2023
(6) At the inquest the court heard evidence from prison officers that they encountered ‘spice’ every day in the prison and the problem of drugs in the prison in seems to be the same as it was in 2019.
(7) At the inquest the Head of Safety at HMP The Mount advised the court that the percentage of positive Mandatory Drug Tests in 2023 (at the date of the inquest) was 26.21% (compared to 32% in 2018).
████████The Head of Safety advised that drugs are brought into HMP The Mount by a number of ways ████████
████████████████████████████████████████████████████████████████████████
████████████████████████████████████████████████████████████████
(9) Four years after the death of Mr Tilbury, drugs and alcohol are still widely available in HMP The Mount, and continue to create a significant 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 complete required intelligence-led searches
Wider context from the report “(1) In May 2018 (16 months before Mr Tilbury’s death) HMP the Mount was subject to an inspection by HM Inspectorate for Prisons. The Inspectors found that levels of violence were comparatively high and mostly related to drugs and debt. They found that less than half of required intelligence led searches were completed and most suspicion drugs tests were missed. They reported that mandatory drug testing indicated that nearly a third of prisoners were using illicit drugs, and that this undermined the prison’s ability to remain safe. The inspectors found that drug supply reduction work was weak and not embedded in the wider strategy, and that half of the prisoners said it was easy to access illicit drugs. The proportion of positive mandatory drug tests, including for psychoactive substances (████████), was high at 32%.
(2) In the report of the Independent Monitoring Board for the year to February 2019 it was noted that drugs were widely available in the prison.
(3) Mr Tilbury died on 24th September 2019 and was found dead in his cell. The medical cause of his death was established by the pathologist at the inquest as respiratory depression caused by the combined use synthetic cannabinoids and alcohol.
(4) The Prisons and Probation Ombudsman carried out an independent investigation into the death of Mr Tilbury on 24th September 2019 at the Mount. The report was produced, as a result of this investigation, in March 2020. The report concluded that it was extremely troubling that Mr Tilbury was able to access and use illicit substances, including Psychoactive Substances, with apparent ease at The Mount, particularly as he lived on a wing for prisoners with substance misuse issues. The report concluded that much more needed to be done to tackle the issue of illicit substances at the prison, and the Governor should ensure that key drug issues at the Mount are identified and that the prison’s local drug strategy be appropriately revised to address them.
(5) Since the death of Mr Tilbury, and the Prisons and Probation Ombudsman’s, report four other prisoners have died at HMP The Mount as a result of taking ████████, namely:
a. Prisoner X ████████ – died on 14th July 2022
b. Prisoner Y ████████ – died on 25th July 2022
c. Prisoner Z ████████ – died on 6th January 2023
d. Prisoner W ████████ – died on 26th January 2023
(6) At the inquest the court heard evidence from prison officers that they encountered ‘spice’ every day in the prison and the problem of drugs in the prison in seems to be the same as it was in 2019.
(7) At the inquest the Head of Safety at HMP The Mount advised the court that the percentage of positive Mandatory Drug Tests in 2023 (at the date of the inquest) was 26.21% (compared to 32% in 2018).
████████The Head of Safety advised that drugs are brought into HMP The Mount by a number of ways ████████
████████████████████████████████████████████████████████████████████████
████████████████████████████████████████████████████████████████
(9) Four years after the death of Mr Tilbury, drugs and alcohol are still widely available in HMP The Mount, and continue to create a significant 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 Widespread availability of drugs and alcohol in the prison
Wider context from the report “(1) In May 2018 (16 months before Mr Tilbury’s death) HMP the Mount was subject to an inspection by HM Inspectorate for Prisons. The Inspectors found that levels of violence were comparatively high and mostly related to drugs and debt. They found that less than half of required intelligence led searches were completed and most suspicion drugs tests were missed. They reported that mandatory drug testing indicated that nearly a third of prisoners were using illicit drugs, and that this undermined the prison’s ability to remain safe. The inspectors found that drug supply reduction work was weak and not embedded in the wider strategy, and that half of the prisoners said it was easy to access illicit drugs. The proportion of positive mandatory drug tests, including for psychoactive substances (████████), was high at 32%.
(2) In the report of the Independent Monitoring Board for the year to February 2019 it was noted that drugs were widely available in the prison .
(3) Mr Tilbury died on 24th September 2019 and was found dead in his cell. The medical cause of his death was established by the pathologist at the inquest as respiratory depression caused by the combined use synthetic cannabinoids and alcohol.
(4) The Prisons and Probation Ombudsman carried out an independent investigation into the death of Mr Tilbury on 24th September 2019 at the Mount. The report was produced, as a result of this investigation, in March 2020. The report concluded that it was extremely troubling that Mr Tilbury was able to access and use illicit substances, including Psychoactive Substances, with apparent ease at The Mount, particularly as he lived on a wing for prisoners with substance misuse issues. The report concluded that much more needed to be done to tackle the issue of illicit substances at the prison, and the Governor should ensure that key drug issues at the Mount are identified and that the prison’s local drug strategy be appropriately revised to address them.
(5) Since the death of Mr Tilbury, and the Prisons and Probation Ombudsman’s, report four other prisoners have died at HMP The Mount as a result of taking ████████, namely:
a. Prisoner X ████████ – died on 14th July 2022
b. Prisoner Y ████████ – died on 25th July 2022
c. Prisoner Z ████████ – died on 6th January 2023
d. Prisoner W ████████ – died on 26th January 2023
(6) At the inquest the court heard evidence from prison officers that they encountered ‘spice’ every day in the prison and the problem of drugs in the prison in seems to be the same as it was in 2019.
(7) At the inquest the Head of Safety at HMP The Mount advised the court that the percentage of positive Mandatory Drug Tests in 2023 (at the date of the inquest) was 26.21% (compared to 32% in 2018).
████████The Head of Safety advised that drugs are brought into HMP The Mount by a number of ways ████████
████████████████████████████████████████████████████████████████████████
████████████████████████████████████████████████████████████████
(9) Four years after the death of Mr Tilbury, drugs and alcohol are still widely available in HMP The Mount, and continue to create a significant 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 complete suspicion drug tests
Wider context from the report “(1) In May 2018 (16 months before Mr Tilbury’s death) HMP the Mount was subject to an inspection by HM Inspectorate for Prisons. The Inspectors found that levels of violence were comparatively high and mostly related to drugs and debt. They found that less than half of required intelligence led searches were completed and most suspicion drugs tests were missed . They reported that mandatory drug testing indicated that nearly a third of prisoners were using illicit drugs, and that this undermined the prison’s ability to remain safe. The inspectors found that drug supply reduction work was weak and not embedded in the wider strategy, and that half of the prisoners said it was easy to access illicit drugs. The proportion of positive mandatory drug tests, including for psychoactive substances (████████), was high at 32%.
(2) In the report of the Independent Monitoring Board for the year to February 2019 it was noted that drugs were widely available in the prison.
(3) Mr Tilbury died on 24th September 2019 and was found dead in his cell. The medical cause of his death was established by the pathologist at the inquest as respiratory depression caused by the combined use synthetic cannabinoids and alcohol.
(4) The Prisons and Probation Ombudsman carried out an independent investigation into the death of Mr Tilbury on 24th September 2019 at the Mount. The report was produced, as a result of this investigation, in March 2020. The report concluded that it was extremely troubling that Mr Tilbury was able to access and use illicit substances, including Psychoactive Substances, with apparent ease at The Mount, particularly as he lived on a wing for prisoners with substance misuse issues. The report concluded that much more needed to be done to tackle the issue of illicit substances at the prison, and the Governor should ensure that key drug issues at the Mount are identified and that the prison’s local drug strategy be appropriately revised to address them.
(5) Since the death of Mr Tilbury, and the Prisons and Probation Ombudsman’s, report four other prisoners have died at HMP The Mount as a result of taking ████████, namely:
a. Prisoner X ████████ – died on 14th July 2022
b. Prisoner Y ████████ – died on 25th July 2022
c. Prisoner Z ████████ – died on 6th January 2023
d. Prisoner W ████████ – died on 26th January 2023
(6) At the inquest the court heard evidence from prison officers that they encountered ‘spice’ every day in the prison and the problem of drugs in the prison in seems to be the same as it was in 2019.
(7) At the inquest the Head of Safety at HMP The Mount advised the court that the percentage of positive Mandatory Drug Tests in 2023 (at the date of the inquest) was 26.21% (compared to 32% in 2018).
████████The Head of Safety advised that drugs are brought into HMP The Mount by a number of ways ████████
████████████████████████████████████████████████████████████████████████
████████████████████████████████████████████████████████████████
(9) Four years after the death of Mr Tilbury, drugs and alcohol are still widely available in HMP The Mount, and continue to create a significant risk of future deaths.
” Open source report
25 Aug 2023 Stephen Weatherley · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 3 Absence of written guidance for suspected drug swallow assessment, referral and monitoring View source Inadequate MOJ oversight and monitoring of recording and retention of data View source Failure to maintain and retain complete contemporaneous records and documents 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
Stephen Weatherley · 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 Weatherley died at HMP Thameside from the toxic effects of cocaine and methadone after swallowing a package containing a drug during a prison visit. The report identifies concerns about the visitor being allowed an open visit, inadequate investigation and monitoring after the visit, poor record keeping and data retention, and the absence of written guidance for suspected drug swallows.
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 Absence of written guidance for suspected drug swallow assessment, referral and monitoring
Wider context from the report “Absence of a written policy at HMP Thameside if there is a suspected drug swallow.
15. In 2018, there was no written policy as to what should occur where there may have been a drugs swallow but it had not been seen immediately by staff or on CCTV. That remains the case.
16. In SW’s case, the body scanner had not been installed in 2018 and following a search of SW and review of the CCTV he was returned to the wing (and not taken CSU or healthcare). The jury found that there was insufficient investigation after the visit and a lack of implementation of precautionary measures.
17. I was informed by HMP Thameside on 12th June 2023, that in a similar situation the prisoner would now be scanned using the body scanner. If the prisoner had concealed an item in a bodily orifice he would be taken to CSU. If he had swallowed an item, he would be taken to Healthcare. I was told this is standard practice but is not written down. Further, if a prisoner refused a scan, he would be taken to CSU. The management of the prisoner in CSU would be the subject of an algorithm deployed by Healthcare, which then produced guidance as to monitoring. There would be liaison between Healthcare and CSU to ensure the prisoner was appropriately monitored.
18. At present the system relies upon good communications/decision making between healthcare and discipline staff and individual judgement.
19. I remain concerned as to the absence of written guidance for officers and the risk that if they are not aware of the above “informal” guidance, a prisoner may not be taken to the correct location (CSU or Healthcare) and/or there may not be appropriate monitoring . I appreciate that each situation is fact specific and drafting written guidance may be difficult.
” 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 MOJ oversight and monitoring of recording and retention of data
Wider context from the report “Data recording and retention in HMP Thameside/oversight by MOJ
1. Key documents around decision making by Serco officers in respect of open/closed visits for SW were lost.
2. Record keeping of key events on 23rd and 24th February 2018 was not properly completed by Serco officers on the central system for recording, operated by the MOJ (“PNOMIS”).
3. There were only 3 entries on SW’s PNOMIS record in the 5 months he was at HMP Thameside.
4. The PPO investigator encountered delays in obtaining documents, unclear and incomplete records from HMP Thameside. The decision making around closed visits/reviews was requested by the PPO in September 2018 and had not been provided at the time the PPO report in April 2019, which pre-dated the electronic migration of data in October 2020 (see below).
5. Solicitors representing HMP Thameside informed me on 30 March 2023 that the prison was unable to adduce the 2018 versions of the local standard operating procedures in place at the time of SW’s death (i.e re visits procedures) due to a large IT migration which took place around 18 months prior (October 2020), which resulted in the loss of some historical data saved on their systems.
6. I subsequently requested the underlying decision making around closed visits/review (as I had the PPO before me) and was informed that these documents were no longer available, also lost in the electronic migration.
7. I was then informed (during the Inquest), that material may have been lost due to officers storing it on local desktop computers and not uploading it to the main system.
8. Having expressed concerns about record-keeping and data retention, I heard PFD evidence on 12th June 2023 about a limited internal audit of PNOMIS which revealed concerns over 15% of the records reviewed. I heard evidence that contract managers oversee the contract between the MOJ and Serco, reporting monthly on contract delivery indicators. They do not conduct specific checks on PNOMIS record keeping/audits of the same.
9. I also heard evidence on 12th June 2023 that there remain two systems for record keeping, the Serco system, CMS and the national MOJ system, PNOMIS. CMS requires a layer of officer input (uploading and/or printing off) to ensure retention and distribution. A notice to staff dated 23rd June 2023 reminded them to upload material to CMS.
10. A witness statement from the director of HMP Thameside dated 26th June 2023 further explained the contractual relationship between the MOJ and Serco including the 28 contract delivery indicators. There is also a contractual requirement to ensure compliance with Prison Service Instructions (PSIs) which include PSI 04/2018 which relates to records, information management and retention policy.
11. In this witness statement, the director stated that he had instructed the Serco Assurance Team (independent of the prison team) to conduct a widespread audit of the PNOMIS and Death in Custody files, which will be completed by September 2023. Whilst I am reassured that an independent audit is being conducted, the results are not currently available. SW died in 2018 and the audit was not initiated until June 2023.
12. I accept that there have been improvements. However, given the extent and impact of the deficiencies outlined above, I remain concerned as to whether systems (for both record keeping and retention) have improved sufficiently since 2018.
13. I am also concerned as to the level of oversight and monitoring by the MOJ (having subcontracted to Serco) of recording and retention of data , given that key data was lost, key records were not maintained and the PPO was not provided with documents requested.
14. If key documents are not available/incidents are not recorded contemporaneously, then the PPO and the Inquest process is frustrated. It is more difficult to identify deficiencies and prevent future deaths. Further, if communications are not recorded, there is a risk that relevant factors are not considered when officers are making potentially life-impacting 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 Failure to maintain and retain complete contemporaneous records and documents
Wider context from the report “Data recording and retention in HMP Thameside/oversight by MOJ
1. Key documents around decision making by Serco officers in respect of open/closed visits for SW were lost.
2. Record keeping of key events on 23rd and 24th February 2018 was not properly completed by Serco officers on the central system for recording, operated by the MOJ (“PNOMIS”).
3. There were only 3 entries on SW’s PNOMIS record in the 5 months he was at HMP Thameside.
4. The PPO investigator encountered delays in obtaining documents, unclear and incomplete records from HMP Thameside. The decision making around closed visits/reviews was requested by the PPO in September 2018 and had not been provided at the time the PPO report in April 2019, which pre-dated the electronic migration of data in October 2020 (see below).
5. Solicitors representing HMP Thameside informed me on 30 March 2023 that the prison was unable to adduce the 2018 versions of the local standard operating procedures in place at the time of SW’s death (i.e re visits procedures) due to a large IT migration which took place around 18 months prior (October 2020), which resulted in the loss of some historical data saved on their systems.
6. I subsequently requested the underlying decision making around closed visits/review (as I had the PPO before me) and was informed that these documents were no longer available, also lost in the electronic migration.
7. I was then informed (during the Inquest), that material may have been lost due to officers storing it on local desktop computers and not uploading it to the main system.
8. Having expressed concerns about record-keeping and data retention, I heard PFD evidence on 12th June 2023 about a limited internal audit of PNOMIS which revealed concerns over 15% of the records reviewed. I heard evidence that contract managers oversee the contract between the MOJ and Serco, reporting monthly on contract delivery indicators. They do not conduct specific checks on PNOMIS record keeping/audits of the same.
9. I also heard evidence on 12th June 2023 that there remain two systems for record keeping, the Serco system, CMS and the national MOJ system, PNOMIS. CMS requires a layer of officer input (uploading and/or printing off) to ensure retention and distribution. A notice to staff dated 23rd June 2023 reminded them to upload material to CMS.
10. A witness statement from the director of HMP Thameside dated 26th June 2023 further explained the contractual relationship between the MOJ and Serco including the 28 contract delivery indicators. There is also a contractual requirement to ensure compliance with Prison Service Instructions (PSIs) which include PSI 04/2018 which relates to records, information management and retention policy.
11. In this witness statement, the director stated that he had instructed the Serco Assurance Team (independent of the prison team) to conduct a widespread audit of the PNOMIS and Death in Custody files, which will be completed by September 2023. Whilst I am reassured that an independent audit is being conducted, the results are not currently available. SW died in 2018 and the audit was not initiated until June 2023.
12. I accept that there have been improvements. However, given the extent and impact of the deficiencies outlined above, I remain concerned as to whether systems (for both record keeping and retention) have improved sufficiently since 2018.
13. I am also concerned as to the level of oversight and monitoring by the MOJ (having subcontracted to Serco) of recording and retention of data, given that key data was lost, key records were not maintained and the PPO was not provided with documents requested.
14. If key documents are not available/incidents are not recorded contemporaneously, then the PPO and the Inquest process is frustrated. It is more difficult to identify deficiencies and prevent future deaths. Further, if communications are not recorded , there is a risk that relevant factors are not considered when officers are making potentially life-impacting decisions.
” Open source report
3 Jul 2023 Liam Ryan Wayne Bentley · Prevention of Future Deaths report Mid Kent and Medway
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Concerns raised 1 Insufficient prison staffing levels 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
Liam Ryan Wayne Bentley · 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
Liam Ryan Wayne Bentley was a serving prisoner at HMP Swaleside who had a history of self-harm and expressed fears about other prisoners and suicidal thoughts. He later took his own life, although his intention was unclear. The report identified concerns about inadequate psychological support, failures in self-harm monitoring and care planning, ineffective communication, and staff shortages and training gaps.
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 Insufficient prison staffing levels
Wider context from the report “(1) There was evidence from prison staff from which it was concluded by the jury that the safety of deceased was compromised as a result in staff shortages
(2) The current complement of Band 2 Operational Support Group staff is 71% this is predicted to further reduce to 54%, the current complement of Band 3 Prison Officers is 68% this is predicted to further reduce to 46%.
” Open source report
30 Jun 2023 Victoria STOREY · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 3 Uncertainty about the contents of illicit potent synthetic opiates View source Illicit marketing of potent synthetic opiates as common pharmaceutical opiates View source Failure to control potent synthetic opiates under Class A and Schedule 1 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
Victoria STOREY · 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
Victoria Storey was found deceased in her bedroom on 3 September 2022 after taking an accidental overdose of a potent synthetic opioid that was not licensed for medicinal use. The report raised concerns that the substance was illicitly traded and marketed as common pharmaceutical opiates, that its contents were unknown to users, and that it was not then controlled under the relevant drug legislation despite its high risk of fatal overdose.
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 Uncertainty about the contents of illicit potent synthetic opiates
Wider context from the report “- Due to the nature of the drug in potent synthetic opiates, there is no way for the end user to know what the illicit substance contains.
” 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 Illicit marketing of potent synthetic opiates as common pharmaceutical opiates
Wider context from the report “- ████████ is illicitly traded and marketed as common pharmaceutical opiates. It has potent analgesic effects but is not approved for medicinal use due to the increased risk of adverse events.
” 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 control potent synthetic opiates under Class A and Schedule 1
Wider context from the report “- The Home Office requested advice from the Advisory Council on the Misuse of Drugs (ACMD) on the appropriate domestic control of ████████, and was advised by the ACMD on 18th July 2022 that ████████ (and other similar compounds) should be placed in schedule 1 of the Misuse of Drugs Regulations 2001 and listed as Class A drugs under the Misuse of Drugs Act 1971. However, at present the Act and Regulations have not been amended to include ████████ and it is unclear if and when this will take place. ████████ is not therefore currently controlled under Class A, Schedule 1, Misuse of Drugs Act 1971 despite its heroin-like effects with a high risk of fatal overdose.
” Open source report
23 Jun 2023 Stephen Kurt Beadman · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 3 Failure to restrict access to potentially harmful male-grooming equipment for prisoners with an identified history of self-harming View source Insufficient specialist psychiatric care for prisoners View source Failure to withdraw potentially harmful male-grooming equipment from use in the prison 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
Stephen Kurt Beadman · 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 Kurt Beadman was a 34-year-old serving prisoner at HMP Wakefield who was found unresponsive after applying a ligature to his neck and died in hospital the following day. The Inquest found that he committed suicide having been bullied by other prisoners. The principal concern was that the prison’s limited consultant psychiatrist resource was insufficient for the complex mental health needs of its prisoner population, creating concern that other deaths may occur.
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 restrict access to potentially harmful male-grooming equipment for prisoners with an identified history of self-harming
Wider context from the report “1) Mr Beadman had a history of self-harming ████████. Nonetheless, he was permitted ████████ in his possession when alone in his cell.
2) For the avoidance of doubt, Mr Beadman took his own life later in the afternoon of 7th April 2021 by applying a ligature to his neck, ████████ to take his own life.
3) The issue of ████████ gives rise to a foreseeable risk.
4) Only six weeks before the 7th April 2021 incident, another prisoner, Carl Shaun Langdell had used a similar type of ████████ to inflict a fatal wound to his neck. A Prevention of Future Death Report dated 21.10.22 was made in that case. A copy is attached, along with the response received from ████████ dated 23.12.22.
5) Evidence was taken at the Inquest in which several people working at the prison expressed support for such ████████ to be withdrawn from use in the prison.
6) It is acknowledged that consideration has been given within the prison service nationally to the withdrawal of ████████ of this type and that this work (including various pilot projects) is ongoing. It is further acknowledged that the difficulties in identifying a workable alternative system of male grooming are considerable. This does not, however, obviate the need to remove a clear source of potential harm from those with an identified history of self-harming.
” 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 specialist psychiatric care for prisoners
Wider context from the report “2) Despite this complex cohort of prisoners, the prison only has one day per week of consultant psychiatrist resource . As the professed principle is equivalence of care with the community, this seems not to be achieved , particularly having regard to the psychological make up of the prisoner population.
3) Evidence taken at the Inquest indicated that further senior psychiatric doctor resource would enable the prison to provide better for the needs of the prisoners .
4) For the avoidance of doubt, it is accepted that Mr Beadman himself was able to see the consultant psychiatrist on 19th October 2021 for 1 hour and again on 25th January 2021 (at which time he was discharged). Notwithstanding that his death on 8th April 2021 cannot be attributed to a lack of psychiatric attention, there is a concern that other long-term inmates in the prison are not receiving the specialist care they probably need . This in turn gives rise to a concern that other deaths may occur.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to withdraw potentially harmful male-grooming equipment from use in the prison
Wider context from the report “1) Mr Beadman had a history of self-harming ████████. Nonetheless, he was permitted ████████ in his possession when alone in his cell.
2) For the avoidance of doubt, Mr Beadman took his own life later in the afternoon of 7th April 2021 by applying a ligature to his neck, ████████ to take his own life.
3) The issue of ████████ gives rise to a foreseeable risk.
4) Only six weeks before the 7th April 2021 incident, another prisoner, Carl Shaun Langdell had used a similar type of ████████ to inflict a fatal wound to his neck. A Prevention of Future Death Report dated 21.10.22 was made in that case. A copy is attached, along with the response received from ████████ dated 23.12.22.
5) Evidence was taken at the Inquest in which several people working at the prison expressed support for such ████████ to be withdrawn from use in the prison.
6) It is acknowledged that consideration has been given within the prison service nationally to the withdrawal of ████████ of this type and that this work (including various pilot projects) is ongoing. It is further acknowledged that the difficulties in identifying a workable alternative system of male grooming are considerable. This does not, however, obviate the need to remove a clear source of potential harm from those with an identified history of self-harming.
” Open source report
16 Jun 2023 Girmaye Guyo Liban · Prevention of Future Deaths report Manchester City
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Concerns raised 1 Lack of a thorough procedure or legal test for assessing nearest relative discharge applications 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
Girmaye Guyo Liban · 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
Girmaye Guyo Liban had a long history of mental health illness and substance abuse, was discharged from detention under the Mental Health Act 1983, remained unwell in the community, went missing on 10 November 2020, and his body was found in a reservoir on 26 November 2020. The concern was that the Nearest Relative Power could enable discharge despite a patient continuing to meet the criteria for detention, without a thorough procedure or legal test for clinicians to apply.
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 thorough procedure or legal test for assessing nearest relative discharge applications
Wider context from the report “The Nearest Relative Power may (as it did in this case) present an opportunity for a patient and/or their Nearest Relative to apply to the Responsible Clinician for discharge in circumstances when the patient remains liable for their continued detention. There does not appear to be a thorough procedure or legal test for clinicians to apply , and thus there is a risk that Responsible Clinicians may be faced with circumstances whereby a patient will be discharged from hospital despite them continuing to meet the criteria for detention .
” Open source report
2 Jun 2023 Andrew DEAN · Prevention of Future Deaths report East Sussex
View report summary
Concerns raised 2 Lack of clearly defined processes for new prisoners to make first contact with family members when first-night contact does not take place View source Lack of clearly defined processes for logging and handling safety-related incoming calls to the central switchboard from family members 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
Andrew DEAN · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 26 March 2021, Andrew Dean was found with a ligature around his neck in a cell at HMP Lewes and was declared dead later that morning. The concerns related to the lack of clearly defined processes for ensuring that new prisoners could successfully make first contact with family members and for logging and responding to incoming calls from family members concerned about a prisoner’s safety or requesting a welfare check.
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 clearly defined processes for new prisoners to make first contact with family members when first-night contact does not take place
Wider context from the report “I am concerned that there are no clearly defined processes to ensure that new prisoners can successfully make first contact with family members (when this does not take place on the first night) and for logging and handling incoming calls to the central switchboard from family members with concerns about a prisoner’s safety and/or requesting a welfare check.
” 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 clearly defined processes for logging and handling safety-related incoming calls to the central switchboard from family members
Wider context from the report “I am concerned that there are no clearly defined processes to ensure that new prisoners can successfully make first contact with family members (when this does not take place on the first night) and for logging and handling incoming calls to the central switchboard from family members with concerns about a prisoner’s safety and/or requesting a welfare check .
” 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