Concerns raised 6 Delays of over a month in obtaining best evidence through video interview or otherwise View source Lack of formalised, guaranteed funding for long-term therapy and recovery provision View source Failure to extend long-term therapy and recovery provision to domestic abuse and child sexual abuse View source Lack of available DC capacity to progress rape and serious sexual assault complaints View source Failure of the railway bridge parapet to meet statutory obligations View source Delays in long-term therapy and recovery support after sexual violence 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
Tamsin Ann Dolamore · 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
Tamsin Ann Dolamore died aged 24 after falling from a railway bridge onto railway lines on 8 January 2018; the inquest recorded an Open Conclusion and the medical cause of death as effects of multiple injuries. The substantive concerns included delays in appointing a Sexual Offence Liaison Officer, delays and gaps in mental-health and support services, and insufficient police resources causing delays in progressing rape and serious sexual assault complaints.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Delays of over a month in obtaining best evidence through video interview or otherwise
Wider context from the report “I was informed by ████████ that as of January this year, there were 600 open cases of rape or serious sexual assault. I was told additionally that there are over 20 vacancies for DCs to progress these complaints. One consequence was that it was taking over a month to achieve best evidence through video interview or otherwise .
████████ agreed that the lack of available DCs meant that both the quality and amount of work that could be done were affected.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 formalised, guaranteed funding for long-term therapy and recovery provision
Wider context from the report “There are some steps being taken towards the provision of a more joined-up approach through a pენinsula sexual violence pathfinder [funded by NHSE] which brings together commissioners and services across Devon, Cornwall, Plymouth and Torbay to pilot new approaches to longer- term recovery support for those impacted by sexual violence. Locally, a joined- up service called Safer Futures [a partnership between First Light and Barnardos] has been commissioned by Safer Cornwall which includes Cornwall Council, the Integrated Care Board, NHSE and others.
I am concerned that the provision of long-term therapy and recovery for the survivors of rape and sexual violence, which should be extended to include domestic abuse and child sexual abuse, needs to be formalised and provided with a guaranteed level of funding . You may wish to consider if this should be on a statutory basis. No one should have to wait half a year for help after being assaulted.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 extend long-term therapy and recovery provision to domestic abuse and child sexual abuse
Wider context from the report “There are some steps being taken towards the provision of a more joined-up approach through a pენinsula sexual violence pathfinder [funded by NHSE] which brings together commissioners and services across Devon, Cornwall, Plymouth and Torbay to pilot new approaches to longer- term recovery support for those impacted by sexual violence. Locally, a joined- up service called Safer Futures [a partnership between First Light and Barnardos] has been commissioned by Safer Cornwall which includes Cornwall Council, the Integrated Care Board, NHSE and others.
I am concerned that the provision of long-term therapy and recovery for the survivors of rape and sexual violence, which should be extended to include domestic abuse and child sexual abuse , needs to be formalised and provided with a guaranteed level of funding. You may wish to consider if this should be on a statutory basis. No one should have to wait half a year for help after being assaulted.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 DC capacity to progress rape and serious sexual assault complaints
Wider context from the report “I was informed by ████████ that as of January this year, there were 600 open cases of rape or serious sexual assault. I was told additionally that there are over 20 vacancies for DCs to progress these complaints . One consequence was that it was taking over a month to achieve best evidence through video interview or otherwise.
████████ agreed that the lack of available DCs meant that both the quality and amount of work that could be done were affected .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 railway bridge parapet to meet statutory obligations
Wider context from the report “Tamsin fell approximately 21.5’ from Menacuddle Hill/North Street railway bridge in St Austell. During the course of the investigation, enquiries were made relating to the parapet at the bridge. Please find attached:
- Report of ████████ at Strange, Strange & Gardner, Consultant Engineers, dated 30/8/18. You will note his view that the parapet does not meet the obligations of the Railway Clause Consolidation Act 1845 ;
- Email from ████████ dated 14/12/18;
- Email from ████████ dated 24/5/19;
- Email from ████████, Cormac, dated 15/7/19.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Delays in long-term therapy and recovery support after sexual violence
Wider context from the report “There are some steps being taken towards the provision of a more joined-up approach through a pენinsula sexual violence pathfinder [funded by NHSE] which brings together commissioners and services across Devon, Cornwall, Plymouth and Torbay to pilot new approaches to longer- term recovery support for those impacted by sexual violence. Locally, a joined- up service called Safer Futures [a partnership between First Light and Barnardos] has been commissioned by Safer Cornwall which includes Cornwall Council, the Integrated Care Board, NHSE and others.
I am concerned that the provision of long-term therapy and recovery for the survivors of rape and sexual violence , which should be extended to include domestic abuse and child sexual abuse, needs to be formalised and provided with a guaranteed level of funding. You may wish to consider if this should be on a statutory basis. No one should have to wait half a year for help after being assaulted .
” 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 Increase funding for victims’ services to more than four times its 2009/10 level by 2024/25, including support for sexual violence and domestic abuse services.
Verbatim wording from the response “Your report noted the improvement and increases in funding for Sexual Assault Referral Centres (SARCs) across Devon & Cornwall. Indeed, to better support victims and meet demand for services we are more than quadrupling funding for victims’ services by 2024/25, up from £4.1 million in 2009/10. This includes up to £6.6 million for services supporting victims of sexual violence and domestic abuse, and funding to increase the number of Independent Sexual Violence Advisors (ISVAs) and Independent Domestic Violence Advisors (IDVAs) by 300, to over 1,000 by 2024/25. In addition, in September 2022, the Ministry of Justice and Home Office announced a joint fund for Violence Against Woman and Girls (VAWG) ‘by and for’ services. This will run over two years (2023/24 to 2024/25) and total up to £6 million.” 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 Establish a statutory duty for Police and Crime Commissioners, Integrated Care Boards and local authorities to collaborate when commissioning specified victim support services.
Verbatim wording from the response “As you note, the Victims and Prisoners Bill is currently going through Parliament. To respond to your recommendation on introducing statutory funding, the Bill is not the right vehicle to set out how future funding may be directed. This is determined by HM Treasury as part of the Spending Review who decide departmental expenditure limits and set out a plan for how public money will be spent over a multi-year period, in line with government priorities.” 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 Operate a joint Violence Against Women and Girls fund supporting ‘by and for’ services over 2023/24 to 2024/25, with funding of up to £6 million.
Verbatim wording from the response “Your report noted the improvement and increases in funding for Sexual Assault Referral Centres (SARCs) across Devon & Cornwall. Indeed, to better support victims and meet demand for services we are more than quadrupling funding for victims’ services by 2024/25, up from £4.1 million in 2009/10. This includes up to £6.6 million for services supporting victims of sexual violence and domestic abuse, and funding to increase the number of Independent Sexual Violence Advisors (ISVAs) and Independent Domestic Violence Advisors (IDVAs) by 300, to over 1,000 by 2024/25. In addition, in September 2022, the Ministry of Justice and Home Office announced a joint fund for Violence Against Woman and Girls (VAWG) ‘by and for’ services. This will run over two years (2023/24 to 2024/25) and total up to £6 million.” 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 The Chief Constable is responsible for responding to concerns about open rape and serious assault cases and Detective Constable vacancies.
Verbatim wording from the response “Lastly, you raise concerns about the serious matter of the number of open rape and serious assault causes and vacancies at Detective Constable level. As you have sent a separate PFD to the Chief Constable, I trust they will respond fully on the matter.” 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 HM Treasury determines departmental expenditure limits and future statutory victim-support funding, so the Victims and Prisoners Bill is not the appropriate vehicle.
Verbatim wording from the response “As you note, the Victims and Prisoners Bill is currently going through Parliament. To respond to your recommendation on introducing statutory funding, the Bill is not the right vehicle to set out how future funding may be directed. This is determined by HM Treasury as part of the Spending Review who decide departmental expenditure limits and set out a plan for how public money will be spent over a multi-year period, in line with government priorities.” Source location Response from Ministry of Justice
Open published response
16 May 2023 Stuart Michael ROBINSON · Prevention of Future Deaths report Liverpool and the Wirral
View report summary
Concerns raised 1 Failure to ensure mental health team attendance at ACCT reviews 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
Stuart Michael ROBINSON · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Stuart Michael Robinson, aged 20, died by suicide in prison on 25 April 2021 after a history of attempted suicide and self-harm. The inquest highlighted the need for a registered mental health nurse or other mental health expert to attend reviews for prisoners subject to ACCT procedures, particularly where there had been repeated self-harm.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure mental health team attendance at ACCT reviews
Wider context from the report “This inquest highlighted the significant numbers of prisoners who enter the prison system with known or undiagnosed mental health issues. Whilst ACCT 6 requires multidisciplinary attendance at review meetings, this case highlighted the need for specific attendance of an RMN or other mental health expert at any review , (Mr Robinson had repeatedly self harmed prior to committing suicide but had presented without concern at each review which had been carried out without any input from the mental health team ). The prison in question now operates a local policy to ensure someone from the mental health team attends all ACCT reviews irrespective of other disciplines attending. This has enabled the prison to identify issues which may not be picked up by other professionals involved, to enable support to be put in place by way of separate care plans which has had a notable impact upon SASH in the prison.
” Open source report
12 May 2023 Angela Vanessa CRADDOCK · Prevention of Future Deaths report Cheshire
View report summary
Concerns raised 3 Failure to conduct pre-sentence or post-sentence review View source Failure to include restraining order breach information in OASys risk assessments and prison recall reports and reviews View source Failure to ensure receipt of restraining order conditions by relevant staff View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Angela Vanessa CRADDOCK · 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
Angela Vanessa Craddock died on 11 April 2018 after an offender attended her address and inflicted survivable injuries. Concerns included failures to identify and share information about breaches of a restraining order, incomplete risk assessment and recall information, and ineffective deployment of police resources to enforce the recall notice.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct pre-sentence or post-sentence review
Wider context from the report “The offender had not been subject of any pre-sentence or post sentence review following conviction on 19 February 2018 for possession of a knife and a section 39 assault on Angela Craddock. The offender was sentenced to 6 months imprisonment and the Restraining order was granted for 12 months.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 include restraining order breach information in OASys risk assessments and prison recall reports and reviews
Wider context from the report “During the 39 days between conviction and release the offender phoned Angela Craddock on 160 occasions. Most of the calls did not connect. The offender also wrote several letters to Angela Craddock from prison in breach of the Restraining Order.
Details of the Restraining Order were sent to HMP Altcourse and on receipt a paper copy of the conditions were placed in an envelope to be delivered to the Public Protection Department. This was never received so the relevant staff were not aware of the Restraining Order.
Consequently, upon release on licence the community rehabilitation service were unaware of the breaches of the Restraining Order and were unable to include this information in the OASys risk assessment or the prison recall report and review , ultimately sent on to the police for the enforcement of the recall notice.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 receipt of restraining order conditions by relevant staff
Wider context from the report “During the 39 days between conviction and release the offender phoned Angela Craddock on 160 occasions. Most of the calls did not connect. The offender also wrote several letters to Angela Craddock from prison in breach of the Restraining Order.
Details of the Restraining Order were sent to HMP Altcourse and on receipt a paper copy of the conditions were placed in an envelope to be delivered to the Public Protection Department. This was never received so the relevant staff were not aware of the Restraining Order.
Consequently, upon release on licence the community rehabilitation service were unaware of the breaches of the Restraining Order and were unable to include this information in the OASys risk assessment or the prison recall report and review, ultimately sent on to the police for the enforcement of the recall notice.
” Open source report
27 Mar 2023 Miss Kayleigh BURNS · Prevention of Future Deaths report Warwickshire
View report summary
Concerns raised 1 Increasing use of Nitrous Oxide by young persons 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
Miss Kayleigh BURNS · 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
Miss Kayleigh Burns, aged 16, ingested nitrous oxide from canisters, developed wheezing, collapsed, was resuscitated and died the following day in hospital. The substantive concern was whether the legal framework for nitrous oxide should be reviewed in light of its seemingly increasing use, particularly by young people.
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 Increasing use of Nitrous Oxide by young persons
Wider context from the report “Whether the present legal framework concerning Nitrous Oxide should be reviewed, in the light of this death, having regard to the seemingly increasing use of Nitrous Oxide particularly by young persons .
” Open source report
5 Jan 2023 Floyd Everton CARRUTHERS · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 2 Lack of national and local training for effective implementation of adult safeguarding policy View source Inadequate safeguarding escalation process for non-violent, non-self-harm-related injurious activity 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
Floyd Everton CARRUTHERS · 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
Floyd Everton Carruthers was detained at HMP Birmingham and died in hospital on 14 June 2021 after developing infective endocarditis, cardiac tamponade, and multi-organ failure. The report raises concerns about inadequate safeguarding training and escalation processes, insufficient record keeping and handover, and failures to refer him to healthcare despite missed meals and not leaving his cell. The jury concluded that his death was contributed to by neglect.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Lack of national and local training for effective implementation of adult safeguarding policy
Wider context from the report “1. At the time Mr Carruthers resided in HMP Birmingham, National Offender Management Service, Adult Safeguarding in Prison Policy, PSI 16/2015 dated 31/3/19 was in force. This policy states at paragraph 1.10 (under the heading "Mandatory Actions") "Governors must have systems in place to protect adult prisoners from abuse and neglect". At paragraph 2.4 the policy states "Neglect also includes self-neglect, which covers a wide range of behaviour such as neglecting to care for one's personal hygiene, health or surroundings and behaviour such as hoarding". My concern is that while there is a national policy dealing with safeguarding, to include instances of self-neglect, no adequate training exists at either national or local level to ensure the effective implementation of that policy .
2. While evidence was heard from prison staff detailing a number of potential escalation routes for what might be termed 'social isolation' (an instance, as with Mr Carruthers, where they had not left their cell for a period of days but had not been observed to have were self isolating), notably ACCT and CISP, none of the officers appeared aware of a corresponding process for raising safeguarding issues. The known escalation routes (ACCT and CISP) are more focussed on violence and self-harm, leaving at the very least a conceptual gap in how best to deal with injurious activity which is neither violent nor directly/obviously contributory to self-harm, such as self-neglect. My concern is that the existing safeguarding escalation process is either inadequate, inappropriately trained or both
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 escalation process for non-violent, non-self-harm-related injurious activity
Wider context from the report “2. While evidence was heard from prison staff detailing a number of potential escalation routes for what might be termed 'social isolation' (an instance, as with Mr Carruthers, where they had not left their cell for a period of days but had not been observed to have were self isolating), notably ACCT and CISP, none of the officers appeared aware of a corresponding process for raising safeguarding issues . The known escalation routes (ACCT and CISP) are more focussed on violence and self-harm, leaving at the very least a conceptual gap in how best to deal with injurious activity which is neither violent nor directly/obviously contributory to self-harm, such as self-neglect . My concern is that the existing safeguarding escalation process is either inadequate, inappropriately trained or both
” Open source report
2 Dec 2022 Lewis Steven Johnson · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 12 Failure to assess an unresponsive prisoner and consider CPR before death is certified View source Failure to consider defibrillator use during a cardiac emergency View source Delays in providing CPR after cardiac arrest View source Failure to consider placing an unresponsive prisoner in the recovery position View source Failure to provide annual refresher training in CPR and defibrillator use for night patrol staff View source Failure to train OSG officers to carry out CPR View source Failure of prison officers to initiate or coordinate CPR in an emergency View source Foreseeable self-harm emergencies among prisoners View source Lack of overnight healthcare staff in the prison View source Failure to train night patrol staff to respond effectively to ligature or other self-harm incidents View source Outdated defibrillator training for prison officers View source Lack of express instruction to carry out CPR pending the arrival of qualified medical professionals View source See 9 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
Lewis Steven Johnson · 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
Lewis Steven Johnson was found unresponsive with a neck ligature at HMP Wealstun on 12 December 2019 and later died in hospital following a further cardiac arrest. The report raised concerns about the absence of overnight healthcare staff and the prison officers’ delayed and inadequate response, including lack of CPR, defibrillator use and consideration of the recovery position.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to assess an unresponsive prisoner and consider CPR before death is certified
Wider context from the report “(5) The officer acting as ████████ attended the cell but did not think about CPR , believing Mr Johnson to be already dead (notwithstanding that none of the discipline officers present had any medical qualifications to certify death ). He had undertaken defibrillator training “many years ago”.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to consider defibrillator use during a cardiac emergency
Wider context from the report “(6) The four prison officers present in the cell did not discuss the need for CPR. The possibility of using a defibrillator was not mentioned . Mr Johnson was left in the cell in a seated position without the wisdom of placing him in the recovery position being 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 Delays in providing CPR after cardiac arrest
Wider context from the report “(7) The medical evidence available at the Inquest indicated “Effective CPR more than doubles the chance of someone surviving a cardiac arrest ”. Furthermore, the Resuscitation Council UK advises “provide chest compressions as soon as possible after cardiac arrest is confirmed ”.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to consider placing an unresponsive prisoner in the recovery position
Wider context from the report “(6) The four prison officers present in the cell did not discuss the need for CPR. The possibility of using a defibrillator was not mentioned. Mr Johnson was left in the cell in a seated position without the wisdom of placing him in the recovery position being 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 provide annual refresher training in CPR and defibrillator use for night patrol staff
Wider context from the report “(8) The value of all night patrol staff (particularly in a prison without 24 hour healthcare provision) being trained to provide effective CPR and use a defibrillator competently was recognised at the inquest, along with the wisdom of this being refreshed annually .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 OSG officers to carry out CPR
Wider context from the report “(4) The OSG officer who encountered the situation involving Mr Johnson around 04:45 had not been trained to carry out CPR .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure of prison officers to initiate or coordinate CPR in an emergency
Wider context from the report “(6) The four prison officers present in the cell did not discuss the need for CPR . The possibility of using a defibrillator was not mentioned. Mr Johnson was left in the cell in a seated position without the wisdom of placing him in the recovery position being 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 Foreseeable self-harm emergencies among prisoners
Wider context from the report “(2) The incidence of self-harm incidents amongst prisoners (both in 2019 and today) make such emergencies foreseeable .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 overnight healthcare staff in the prison
Wider context from the report “(1) HMP Wealstun does not have nurses or other healthcare staff in the prison during the night .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 night patrol staff to respond effectively to ligature or other self-harm incidents
Wider context from the report “(3) In the absence of healthcare staff being immediately available, the night patrol staff should be trained to respond effectively to ligature or other self-harm incidents .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Outdated defibrillator training for prison officers
Wider context from the report “(5) The officer acting as ████████ attended the cell but did not think about CPR, believing Mr Johnson to be already dead (notwithstanding that none of the discipline officers present had any medical qualifications to certify death). He had undertaken defibrillator training “many years ago” .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 express instruction to carry out CPR pending the arrival of qualified medical professionals
Wider context from the report “(9) The inquest noted that there is currently no express direction in PSI 03/2013 or other instruction to carry out CPR pending the arrival of paramedics or other qualified medical professional , when a prisoner is found in an unresponsive condition following a ligature incident .
” Open source report
21 Oct 2022 Carl Shaun Langdell · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 1 Failure to prevent prisoners at known chronic risk of suicide or self-harm from possessing items when alone in locked cells overnight 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
Carl Shaun Langdell · 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
Carl Shaun Langdell was discovered in his locked, single-occupancy prison cell with a significant neck wound and died after suffering cardiac arrest despite emergency treatment. The concerns included his identified chronic risk of suicide or self-harm, recent bizarre and agitated behaviour after refusing medication, and his being permitted to possess an unspecified item while alone in his cell overnight. The inquest recorded a finding of suicide and attributed the death to haemorrhage from a neck incision.
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 prevent prisoners at known chronic risk of suicide or self-harm from possessing items when alone in locked cells overnight
Wider context from the report “(2) He had been identified by a consultant psychiatrist as at “chronic risk of suicide attempts/self-harm attempts which is likely to remain due to the nature of his personality disorder” .
(3) In January 2021 he was observed to be acting in a bizarre and agitated manner after refusing his prescribed medication for the previous month.
(4) Despite this history and the known risk he was permitted under the prevailing ████████ rules at HMP Wakefield to be in possession of ████████ when alone in his locked cell overnight.
” Open source report
Concerns raised 2 Unavailability of shared-record-system access for one care or treatment organisation View source Lack of policy, procedure or guidance on considering when to hold multi-agency information-sharing meetings 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
Lewis Martyn POWTER · 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
Lewis Martyn Powter, an IPP offender with emotionally unstable personality disorder and a long history of drug addiction, died from a self-administered overdose on 10 May 2020 after a period of abstinence and reduced drug tolerance. The concern was that there was no policy or guidance encouraging multi-agency meetings to share information about complex-needs IPP offenders, particularly where one care provider lacked access to the shared record system.
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 shared-record-system access for one care or treatment organisation
Wider context from the report “that, where an IPP offender with complex needs is released and is not subject to MAPPA, but is subject to multi-agency intervention co-ordinated by the National Probation Service, there is no policy/procedure/guidance encouraging consideration to be given to the issues of whether and when to hold multi-agency meetings for the purposes of sharing information about the offender. The need for consideration to be given to holding such meetings is particularly acute where one of the organisations responsible for delivering care/treatment does not have access to the shared record system used by the other two parties .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Lack of policy, procedure or guidance on considering when to hold multi-agency information-sharing meetings
Wider context from the report “that, where an IPP offender with complex needs is released and is not subject to MAPPA, but is subject to multi-agency intervention co-ordinated by the National Probation Service, there is no policy/procedure/guidance encouraging consideration to be given to the issues of whether and when to hold multi-agency meetings for the purposes of sharing information about the offender . The need for consideration to be given to holding such meetings is particularly acute where one of the organisations responsible for delivering care/treatment does not have access to the shared record system used by the other two parties.
” Open source report
27 Jun 2022 Jessica Louise LAVERACK “Jessie” · Prevention of Future Deaths report East Riding and Hull
View report summary
Concerns raised 11 Lack of national recognition of proactive collative vulnerability processes View source DASH form not adequately updated View source Lack of information sharing between agencies View source Lack of national-level complex case forums View source Lack of a single point of contact for information collation, assessment and coordinated proactive action View source Lack of a system to identify and care for vulnerable people outside the “high risk” criteria View source Failure of processes and policies to recognise the link between domestic abuse and suicide View source Insufficient information sharing about sleep deprivation risks and impacts on mental health and suicide View source Lack of a robust information-sharing policy for suicidal ideation, self-harm and vulnerable people View source Unavailability of a shared database for agencies to input common concerns View source Insufficient training and awareness of domestic abuse and suicide risk among front line police officers View source See 8 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Jessica Louise LAVERACK “Jessie” · 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
Jessica Louise LAVERACK “Jessie” had a history of domestic abuse, anxiety and alcohol dependence, and reported suicidal ideation and self-harm before her death. She was found on 2 February 2018, and the medical cause of death was recorded as hanging. The report identified concerns about the lack of a coordinated approach and information sharing between agencies, including for vulnerable people who did not meet the MARAC high-risk threshold.
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 national recognition of proactive collative vulnerability processes
Wider context from the report “(8) The processes of Humber police’s vulnerability hub and DARA forms which show a more proactive, collative approach, are not currently a nationally recognised method of working .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation DASH form not adequately updated
Wider context from the report “(7) Evidence was heard that the DASH form may benefit from updating .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 information sharing between agencies
Wider context from the report “(3) There was a lack of information sharing between all agencies , even those tasked with domestic abuse.
a. There is no one database which is accessible for all agencies to input their common concerns.
b. There is lack of robust policy of information sharing regarding both suicidal ideation, self harm as well as identification of the vulnerable.
It is noted that the Health and Care Act is due to commence on 1st July 2022, which outlines need for interagency working. This may be an ideal opportunity to address these issues.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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-level complex case forums
Wider context from the report “(9) If not already in place, to consider complex case forums on a national level .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 single point of contact for information collation, assessment and coordinated proactive action
Wider context from the report “(4) There is no single point of contact to oversee the collation of all information, to appropriate assess it and to coordinate a structured proactive approach to people with dual or multi diagnosis. This is in both MARAC and for those who are vulnerable but do not meet the “high risk” criteria.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 system to identify and care for vulnerable people outside the “high risk” criteria
Wider context from the report “(2) There is no system to appropriately identify and care for the vulnerable who do not meet the criteria of “high risk” which is covered by MARAC, evidence was heard that a large number of domestic homicide reviews cover victims who have not been rated as “high risk”
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure of processes and policies to recognise the link between domestic abuse and suicide
Wider context from the report “(1) The is a need for the recognition of the link between domestic abuse and suicide. Processes and policies do not seem to include this serious area to the extent that is required.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 information sharing about sleep deprivation risks and impacts on mental health and suicide
Wider context from the report “(11) To consider better information sharing about the risks of sleep deprivation and its impact on mental health and suicide .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Lack of a robust information-sharing policy for suicidal ideation, self-harm and vulnerable people
Wider context from the report “(3) There was a lack of information sharing between all agencies, even those tasked with domestic abuse.
a. There is no one database which is accessible for all agencies to input their common concerns.
b. There is lack of robust policy of information sharing regarding both suicidal ideation, self harm as well as identification of the vulnerable.
It is noted that the Health and Care Act is due to commence on 1st July 2022, which outlines need for interagency working. This may be an ideal opportunity to address these issues.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 a shared database for agencies to input common concerns
Wider context from the report “(3) There was a lack of information sharing between all agencies, even those tasked with domestic abuse.
a. There is no one database which is accessible for all agencies to input their common concerns.
b. There is lack of robust policy of information sharing regarding both suicidal ideation, self harm as well as identification of the vulnerable.
It is noted that the Health and Care Act is due to commence on 1st July 2022, which outlines need for interagency working. This may be an ideal opportunity to address these issues.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Insufficient training and awareness of domestic abuse and suicide risk among front line police officers
Wider context from the report “(5) There is a need to consider better training and awareness of both domestic abuse and risk of suicide for front line police officers.
” 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 The Home Office and Department of Health and Social Care hold responsibility for the majority of concerns and lead related recommendations.
Verbatim wording from the response “Responsibility for the majority of the concerns raised in your report sits with the Home Office and Department of Health and Social Care and we have seen and support the response that the Home Office sent you on 23rd August. However, we have separately considered the third concern in your Report where you refer to a lack of information sharing between agencies, including no singular database for all agencies to input common concerns and a lack of robust policy of information sharing regarding both suicidal ideation, self-harm as well as identification of the vulnerable.” Source location Response from Ministry of Justice
Open published response
Concerns raised 3 Lack of regular access to ACCT training for bank nurses View source Failure to apply ACCT opening criteria to information indicating current self-harm or suicide risk View source Inadequate frequency and currency of ACCT training for prison officers 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
Khalid Abiaz · 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
Khalid Abiaz, a prisoner at HMP Swansea, died in the early hours of 13 September 2016 after being found suspended by a ligature. The report identified concerns that an ACCT was not opened despite suicide warning markers and relevant historical information, and that prison and bank nursing staff may not have received sufficiently frequent or up-to-date ACCT training.
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 regular access to ACCT training for bank nurses
Wider context from the report “2. I heard evidence from the nurse who saw Khalid on reception. This person is an experienced mental health nurse who is now a charge nurse on bank. The nurse told me that he still does at times work through the bank as a mental health nurse in HMP Swansea. At the time of Khalid’s death the Nurse was the mental health nurse working on reception and he completed the first reception health screen for Khalid and he did not open an ACCT. It was unclear what documents the nurse had seen on reception for Khalid but he did not ask prison staff if he could see any documents. The Nurse gave evidence that even if he had known that there was a suicide warning marker on Khalid’s prison escort record this would not have been enough combined with what Khalid said to him to open an ACCT, he relies on Khalid’s presentation. Khalid had been assessed by a consultant psychiatrist as a significant risk to himself a matter of weeks before he was seen by the Nurse in reception. HMP Swansea prison staff and the Nurse were not aware of this information but even if the Nurse had known this information his evidence was that this would not necessarily have been enough for him to open an ACCT, he would consider presentation. The revised ACCT version 6 and accompanying policy guidance set out above makes clear that an ACCT must be opened by any member of staff who receives information that indicates a prisoner may be currently at risk of self-harm or suicide and that this information may come from a prison escort. The answers of the Nurse raise a concern around the level and adequacy of the training on ACCT. The Nurse stated that he has reflected on his practice but that he still places emphasis on what the prisoner says and how they present when considering whether to open an ACCT. I heard evidence that bank nurses were supervised in the prison but that training on ACCT remained the responsibility of HMP Swansea . I am concerned that bank nurse may not receive access to ACCT training including at the required regularity and I am concerned that unless this happens there remains a risk of similar deaths occurring in the future in HMP Swansea
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 apply ACCT opening criteria to information indicating current self-harm or suicide risk
Wider context from the report “2. I heard evidence from the nurse who saw Khalid on reception. This person is an experienced mental health nurse who is now a charge nurse on bank. The nurse told me that he still does at times work through the bank as a mental health nurse in HMP Swansea. At the time of Khalid’s death the Nurse was the mental health nurse working on reception and he completed the first reception health screen for Khalid and he did not open an ACCT. It was unclear what documents the nurse had seen on reception for Khalid but he did not ask prison staff if he could see any documents. The Nurse gave evidence that even if he had known that there was a suicide warning marker on Khalid’s prison escort record this would not have been enough combined with what Khalid said to him to open an ACCT, he relies on Khalid’s presentation. Khalid had been assessed by a consultant psychiatrist as a significant risk to himself a matter of weeks before he was seen by the Nurse in reception. HMP Swansea prison staff and the Nurse were not aware of this information but even if the Nurse had known this information his evidence was that this would not necessarily have been enough for him to open an ACCT, he would consider presentation. The revised ACCT version 6 and accompanying policy guidance set out above makes clear that an ACCT must be opened by any member of staff who receives information that indicates a prisoner may be currently at risk of self-harm or suicide and that this information may come from a prison escort. The answers of the Nurse raise a concern around the level and adequacy of the training on ACCT. The Nurse stated that he has reflected on his practice but that he still places emphasis on what the prisoner says and how they present when considering whether to open an ACCT. I heard evidence that bank nurses were supervised in the prison but that training on ACCT remained the responsibility of HMP Swansea. I am concerned that bank nurse may not receive access to ACCT training including at the required regularity and I am concerned that unless this happens there remains a risk of similar deaths occurring in the future in HMP Swansea
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 frequency and currency of ACCT training for prison officers
Wider context from the report “1. I heard evidence that following a review in 2015 changes to the ACCT document and process were piloted in 10 establishments in 2019 and this included HMP Swansea. As a result a revised ACCT version 6 and accompanying policy guidance was issued. This revised guidance makes clear that an ACCT must be opened by any member of staff who receives information that indicates a prisoner may be currently at risk of self-harm or suicide and that this information may come from a prison escort. However, this requirement is not new. It was clear in my view from the HMP Swansea Suicide and Prevention Policy that was in place at the time of Khalid’s death that a warning marker for suicide on a prison escort record (‘PER’) should result in the opening of an ACCT. The prison officer who saw Khalid first in reception gave evidence that he was an experienced prison officer with over 20 years-experience of working in prisons including 18 years at HMP Swansea. At the time when Khalid came into custody he was an ACCT assessor and remains in this role. He saw Khalid’s PER which stated that Khalid had recently made threats to kill himself and was alleging mental health issues and he saw the NOEMIS transfer report which contained reference to historic ACCTs that Khalid had been in custody and an act of cutting and ligaturing by Khalid 9 months before in December 2015. He did not open an ACCT but referred the nurse who also did not open an ACCT. In his evidence the Prison Officer stated that if a prisoner came into custody now in 2022 with a warning on his PER stating that he has recently made threats to kill himself then this would not be enough to trigger the opening of an ACCT. This view is inconsistent with the mandatory revised ACCT policy guidance that I have set out above. This indicates that the system for training on ACCT in HMP Swansea is inadequate. The Prison Officer could not recall whether his ACCT training was up to date. His training records show that he was ACCT trained in 2005, 2008, 2011 and 2014 and I am told there was training on the new ACCT document that is not recorded in the training records and a further up-skilling session with staff date not specified. I did hear that training was difficult during the Covid 19 pandemic in HMP Swansea, however, ACCT training is required to be carried out with much more frequency than the training provided to the officer on reception and staff should understand that warning markers that require an ACCT to be opened. I am concerned that unless prison officers are provided with frequent ACCT training which is kept up to date then there remains a risk of similar deaths occurring in the future in HMP Swansea.
” Open source report
26 May 2022 SAIFUR RAHMAN · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 5 Lack of a reliable central record of cell fabric history View source Lack of a formal process for communicating and acting on prison cell risk assessment results View source Lack of a formal process for complete visual inspection of ward cells View source Delays in calling code blue emergencies View source Failure of daily and weekly cell fabric checks to identify risks 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
SAIFUR RAHMAN · 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
Saifur Rahman was found in cardiac arrest in his cell at HMP Birmingham on 20 January 2021, was taken to hospital after resuscitation, and died on 23 January 2021. The post-mortem recorded hypoxic/ischaemic encephalopathy associated with external neck compression, and the jury found that his intention was to commit suicide. The report raised concerns about delayed emergency calls, inadequate records of cell history, insufficient cell risk assessments, and the lack of a formal process for prison and mental health staff to inspect and act on cell risks.
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 reliable central record of cell fabric history
Wider context from the report “2. Cell history: the evidence revealed that cell fabric history - including fabric changes, damage and repairs - is safety critical information. Information about the history of cell H3-15 was lost or unclear as it transversed control of the prison changing from G4S to national control in 2018-2019 and there was no prison master/central record . My ongoing concern is that HMP Birmingham does not currently have a master/central record of cell history and there are many Ayes who have a national contract for cell fabric changes and repairs. The evidence was unclear on whether the prison would have access to this safety critical information if the third party contractor changed .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Lack of a formal process for communicating and acting on prison cell risk assessment results
Wider context from the report “4. Prison ████████ risk assessment: the evidence revealed that dynamic daily and weekly prison officer cell fabric checks did not identify the risks within cell H3-15. The evidence from the mental health trust was that as their risk assessment is annual and the environment on ward 2 and ward 3 is dynamic and can quickly change, the prison needs to undertake its own ████████ risk assessment. I was provided with a verbal undertaking that the head of safer custody will undertake the first annual prison cell ████████ risk assessment visually inspecting all 15 x 2 cells 6 months after the NHS risk assessment, and delegate twenty monthly thereafter, resulting in alternating 6 monthly risk assessments. My ongoing concern is that there is no formalised process and consideration needs to be given to how results of the prison ████████ risk assessment is communicated to, and acted upon, by the mental health 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 Lack of a formal process for complete visual inspection of ward cells
Wider context from the report “3. NHS annual ████████ risk assessment: the evidence revealed that the mental health trust assessors had historically only dip-sampled a selection of the 15 x 2 cells on health care ward 2 (physical health) and ward 3 (mental health). They did not record which cells had been visually checked and relied in part on second-hand information from the prison about cell fabric and design. There had not been effective communication between the prison and health care staff. Generally, the trust had 140+ buildings across its entire estate to assess, this was done by two members of the health and safety team, and the assessment of the health care unit at HMP Birmingham was expected to be completed over several hours on one day. I was provided with a verbal undertaking that the trust would now visually inspect all 15 x 2 cells annually. However, this relies exclusively on the co-operation of the prison who have competing tensions given the operationally dynamic and challenging environment, especially if cells are occupied during the assessment. My ongoing concern is that there is no formalised process between the prison and mental health trust to visually inspect each cell . It is recognised prisoners housed on ward 2 and 3 are at a much greater risk of suicide than the general prison population, and general public as a whole, and will spend a great deal of time unobserved in the 15 x 2 cells. Therefore, in my view, visually inspecting 30 cells is not disproportionate to the level of risk and is not comparable to assessing an outpatient building in the community. The dynamic and challenging environment means it is likely all cells cannot be inspected on one visit. Visually inspecting each cell therefore needs to be properly planned and resourced by both the prison and mental health trust and consideration needs to be given to a formal process.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Delays in calling code blue emergencies
Wider context from the report “1. Calling a “code blue”: the evidence revealed that the safety critical code blue call – automatically triggering an emergency response - was delayed by up to 2 minutes. The evidence was inconsistent on whether the cell entry briefing included the identification of an extra officer with a radio, and why therefore an officer in full person protective equipment ran out of the cell and across the ward to where she had left her radio to call the code blue. Delayed code blue calls have been a repeated problem at HMP Birmingham despite it being raised by the Prison and Probation Ombudsman and coroners in earlier regulation 28 reports. My ongoing concern is that delayed code blue calls will continue , and consideration should be given to the effectiveness of training in light of the evidence given by the prison officers at the inquest.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure of daily and weekly cell fabric checks to identify risks
Wider context from the report “4. Prison ████████ risk assessment: the evidence revealed that dynamic daily and weekly prison officer cell fabric checks did not identify the risks within cell H3-15 . The evidence from the mental health trust was that as their risk assessment is annual and the environment on ward 2 and ward 3 is dynamic and can quickly change, the prison needs to undertake its own ████████ risk assessment. I was provided with a verbal undertaking that the head of safer custody will undertake the first annual prison cell ████████ risk assessment visually inspecting all 15 x 2 cells 6 months after the NHS risk assessment, and delegate twenty monthly thereafter, resulting in alternating 6 monthly risk assessments. My ongoing concern is that there is no formalised process and consideration needs to be given to how results of the prison ████████ risk assessment is communicated to, and acted upon, by the mental health trust.
” Open source report
Concerns raised 5 Lack of risk assessments supporting adequate communication with the patient View source Failure to regard identified family members at risk of harm as members of the public for s41 Order purposes View source Overreliance on family members to advocate for the patient View source Failure to incorporate relevant clinical evidence into discharge decisions View source Failure to integrate Criminal Justice recommendations with work undertaken at St Andrew's 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
Marjorie Grayson · 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
Marjorie Grayson died by suicide on 3 September 2020 after falling from a first-floor bedroom window at her home. The report identified concerns about the use of a hospital order without additional restrictions, inadequate consideration of the seriousness of her previous offence and impulse-control risks, limited face-to-face contact after discharge during the Covid-19 pandemic, and insufficient support and communication for her family.
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 risk assessments supporting adequate communication with the patient
Wider context from the report “7. Sheffield Health and Social Care Trust did not have risk assessments which supported adequate communication with Mrs Grayson herself and instead placed an overburden on her family to advocate for her
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 regard identified family members at risk of harm as members of the public for s41 Order purposes
Wider context from the report “4. I am unclear why members of Mrs Grayson's family, who do not reside with her ordinarily and at the time of her offending, are not regarded as members of the public for the purposes of a s41 Order . The risk of harm to them was clear in the mind of the author and had they been regarded as members of the public this may have led to a s41 Order being made which, although potentially making no difference in this case, may do so in others.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Overreliance on family members to advocate for the patient
Wider context from the report “7. Sheffield Health and Social Care Trust did not have risk assessments which supported adequate communication with Mrs Grayson herself and instead placed an overburden on her family to advocate for her
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 incorporate relevant clinical evidence into discharge decisions
Wider context from the report “5. Sheffield Health and Social Care Trust determined to do with Mrs Grayson upon discharge did not pay sufficient heed to the clinical evidence obtained by the Ministry of Justice and which was reflected in the practice at St Andrew's.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 integrate Criminal Justice recommendations with work undertaken at St Andrew's
Wider context from the report “6. Sheffield Health and Social Care Trust do not seem to have joined up the actions that were recommended from the Criminal Justice proceedings and the work undertaken at St Andrew's resulting in a discharge which did not adequately reflect the risks to and from Mrs Grayson.
” Open source report
Concerns raised 4 Lack of written instructions for conducting welfare checks View source Unclear allocation of task-list responsibilities during night-shift agency cover View source Gaps in communication of crucial substance-misuse and Naloxone information to Approved Premises View source Lack of auditing of task-list completion and welfare-check performance 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
Jamie Lee Bennett · 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
Jamie Lee Bennett, who had been abstinent from drugs and methadone for approximately eight months, was found unresponsive in his room at Norfolk Park Bail Hostel on 2 May 2020 and was pronounced deceased by paramedics. The report identified concerns about incomplete sharing of his substance-misuse and Naloxone information, reduced support after release, unclear responsibilities and inadequate training and auditing for welfare checks, and a delay in calling emergency services.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Lack of written instructions for conducting welfare checks
Wider context from the report “The evidence was unclear as to who will carry out actions on the task lists on a night shift when a Sodexo worker was replaced by agency staff. There is no audit process in place to ensure staff are carrying out tasks in accordance with the lists issued
There are no written instructions on how to conduct welfare checks . There is no audit process in place to ensure staff are conducting welfare checks appropriately
It is my opinion there is a risk that future deaths may occur unless there are:
• Clear, written instructions on how to conduct welfare checks
• Clarity around which member of staff will be responsible for which task list, particularly on a night shift when a Sodexo worker is replaced by agency staff
• An audit process put in place to ensure staff are carrying out tasks in accordance with the lists issued and in particular are conducting welfare checks appropriately
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Unclear allocation of task-list responsibilities during night-shift agency cover
Wider context from the report “The evidence was unclear as to who will carry out actions on the task lists on a night shift when a Sodexo worker was replaced by agency staff. There is no audit process in place to ensure staff are carrying out tasks in accordance with the lists issued
There are no written instructions on how to conduct welfare checks. There is no audit process in place to ensure staff are conducting welfare checks appropriately
It is my opinion there is a risk that future deaths may occur unless there are:
• Clear, written instructions on how to conduct welfare checks
• Clarity around which member of staff will be responsible for which task list, particularly on a night shift when a Sodexo worker is replaced by agency staff
• An audit process put in place to ensure staff are carrying out tasks in accordance with the lists issued and in particular are conducting welfare checks appropriately
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Gaps in communication of crucial substance-misuse and Naloxone information to Approved Premises
Wider context from the report “There were gaps in the information provided by HMP Moorlands to Norfolk Park Bail Hostel, in particular his history of substance misuse and that Jamie had refused Naloxone. The Court heard evidence that information sharing with third parties is in line with national guidelines, but also that there should have been another report by the offender management services that would have been more detailed and would have given this information to Norfolk Park . I do feel that if Norfolk Park Bail Hostel had that information, they would have been in a better position to support Jamie during those first crucial 48 hours and that may have reduced the risk of him using substances and dying
It is my view there should be a process by which crucial information about a patient is communicated to the Approved Premise , specifically substance misuse history, any substance misuse work, any detox or re-toxification processes undertaken, and whether the patient has accepted or refused Naloxone and any community drugs services referral. It is my view this will assist the Approved Premise to determine the level of support to be offered to a resident, especially those that are released on a Friday and will have limited support from anywhere other than an Approved Premise during the first 48 hours
It is my opinion there is a risk that future deaths may occur unless such a process is developed
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 auditing of task-list completion and welfare-check performance
Wider context from the report “The evidence was unclear as to who will carry out actions on the task lists on a night shift when a Sodexo worker was replaced by agency staff. There is no audit process in place to ensure staff are carrying out tasks in accordance with the lists issued
There are no written instructions on how to conduct welfare checks. There is no audit process in place to ensure staff are conducting welfare checks appropriately
It is my opinion there is a risk that future deaths may occur unless there are:
• Clear, written instructions on how to conduct welfare checks
• Clarity around which member of staff will be responsible for which task list, particularly on a night shift when a Sodexo worker is replaced by agency staff
• An audit process put in place to ensure staff are carrying out tasks in accordance with the lists issued and in particular are conducting welfare checks appropriately
” Open source report
9 Feb 2022 Michelle Louise Jennings · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 6 Lack of ownership in the application of referral and discharge policies View source Lack of a mechanism to implement learning on vulnerable people across police forces and prosecuting agencies View source Failure to provide courts with relevant mental health background information View source Failure to share learning on referral and discharge ownership across mental health trusts View source Failure to assess the public interest and mental health vulnerability when making prosecution decisions View source Delays in access to therapy caused by insufficient trained therapist capacity View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Michelle Louise Jennings · 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
Michelle Louise Jennings had a history of suicidal thoughts and contact with mental health services. She died after delays in accessing therapy, prosecution following a railway incident, and problems with communication and case ownership between mental health teams. The report identified concerns about therapy waiting lists, referral and discharge arrangements, and how prosecuting authorities account for mental health vulnerability.
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 ownership in the application of referral and discharge policies
Wider context from the report “2. The inquest was told that the trust had since Michelle’s death recognised that the lack of ownership created through the application of its referral and discharge policy internally carried an unacceptable risk . Significant changes had been made. However it was unclear if nationally the lesson had been shared and that other mental health trusts had taken similar steps.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 mechanism to implement learning on vulnerable people across police forces and prosecuting agencies
Wider context from the report “3. The evidence before the inquest was that there needed to be a clear understanding by all prosecuting authorities of the impact of a prosecution on someone with a complex mental health background such as Michelle. In Michelle’s case the BTP file reviewer (the nature of the offence Michelle faced meant that it was not a CPS lawyer who made the charging decision) had not correctly applied the public interest test and had not considered the mental health/vulnerability of Michelle Jennings as required to. As a consequence a decision was taken to prosecute her without an assessment of the impact on Michelle and her case was dealt with by the Magistrates Court without them being given the full background in relation to her deteriorating mental health. BTP are as a consequence of Michelle’s death taking steps to address how their prosecution teams should deal with the public interest test and gather information where mental health is an issue. However there is no clear mechanism for such learning and changes (to reduce the risk to life) in relation to vulnerable people such as Michelle to be implemented within the other 42 Police forces in England and Wales or within other agencies responsible for prosecuting criminal offences .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 courts with relevant mental health background information
Wider context from the report “3. The evidence before the inquest was that there needed to be a clear understanding by all prosecuting authorities of the impact of a prosecution on someone with a complex mental health background such as Michelle. In Michelle’s case the BTP file reviewer (the nature of the offence Michelle faced meant that it was not a CPS lawyer who made the charging decision) had not correctly applied the public interest test and had not considered the mental health/vulnerability of Michelle Jennings as required to. As a consequence a decision was taken to prosecute her without an assessment of the impact on Michelle and her case was dealt with by the Magistrates Court without them being given the full background in relation to her deteriorating mental health . BTP are as a consequence of Michelle’s death taking steps to address how their prosecution teams should deal with the public interest test and gather information where mental health is an issue. However there is no clear mechanism for such learning and changes (to reduce the risk to life) in relation to vulnerable people such as Michelle to be implemented within the other 42 Police forces in England and Wales or within other agencies responsible for prosecuting criminal offences.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to share learning on referral and discharge ownership across mental health trusts
Wider context from the report “2. The inquest was told that the trust had since Michelle’s death recognised that the lack of ownership created through the application of its referral and discharge policy internally carried an unacceptable risk. Significant changes had been made. However it was unclear if nationally the lesson had been shared and that other mental health trusts had taken similar steps .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 the public interest and mental health vulnerability when making prosecution decisions
Wider context from the report “3. The evidence before the inquest was that there needed to be a clear understanding by all prosecuting authorities of the impact of a prosecution on someone with a complex mental health background such as Michelle. In Michelle’s case the BTP file reviewer (the nature of the offence Michelle faced meant that it was not a CPS lawyer who made the charging decision) had not correctly applied the public interest test and had not considered the mental health/vulnerability of Michelle Jennings as required to . As a consequence a decision was taken to prosecute her without an assessment of the impact on Michelle and her case was dealt with by the Magistrates Court without them being given the full background in relation to her deteriorating mental health. BTP are as a consequence of Michelle’s death taking steps to address how their prosecution teams should deal with the public interest test and gather information where mental health is an issue. However there is no clear mechanism for such learning and changes (to reduce the risk to life) in relation to vulnerable people such as Michelle to be implemented within the other 42 Police forces in England and Wales or within other agencies responsible for prosecuting criminal offences.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Delays in access to therapy caused by insufficient trained therapist capacity
Wider context from the report “1. The inquest heard evidence that the backlogs for therapy were such that the waiting list at the time she was assessed as being appropriate for step 4 therapy had a two year wait time. Since that time the waiting period had not decreased and was now between 2 -3 years in both primary and secondary care . This was due to a shortage of trained therapists and demands on the service and was a national issue not specific to the CWP trust.
” Open source report
18 Jan 2022 Terance Alfred RADFORD · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 4 Failure of the Home Detention Curfew Policy to require assessment of prisoners’ risk of harm to others View source Lack of a multi-agency information-sharing framework for assessing and managing risk during Home Detention Curfew release View source Policy permitting direct release from segregation of prisoners whose risk of harm cannot be safely managed in the general prison population View source Lack of guidance on responsibility, timing and factors for assessing risk of harm to others 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
Terance Alfred RADFORD · 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
Terance Alfred Radford, aged 87, died at the scene on 19 April 2019 after being struck by a car driven at speed by a male driver. The report identified concerns about the Home Detention Curfew Policy, including the release of prisoners directly from segregation, insufficient assessment of risk to others, and a lack of multi-agency information sharing.
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 the Home Detention Curfew Policy to require assessment of prisoners’ risk of harm to others
Wider context from the report “2. The national Home Detention Curfew Policy does not expressly require consideration or assessment of the prisoner’s risk of harm to others, beyond the suitability of the proposed release address. If a broader assessment of risk of harm to others is anticipated by the Policy, there is no guidance on who should complete the assessment (singular or multi-agency input), when it should be completed, and what factors ought to be considered as part of that assessment.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 multi-agency information-sharing framework for assessing and managing risk during Home Detention Curfew release
Wider context from the report “3. The national Home Detention Curfew Policy contains no framework for multi-agency information sharing with regards to the assessment and management of risk for those deemed eligible for early release under the terms of the Policy.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Policy permitting direct release from segregation of prisoners whose risk of harm cannot be safely managed in the general prison population
Wider context from the report “1. The national Home Detention Curfew Policy Framework permits the release of eligible prisoners directly from the prison's segregation unit, in circumstances where the prisoner has been placed in the segregation unit because the elevated risk of harm they pose to staff and other prisoners cannot be safely managed within the general prison population.
The public may rightly be concerned that prisoners deemed ‘too risky’ to reside within the general prison population; with its strict curfews and regime, use of locked cells, and trained prison personnel with protective gear, can still be released early from their sentence under the terms of the Policy.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 responsibility, timing and factors for assessing risk of harm to others
Wider context from the report “2. The national Home Detention Curfew Policy does not expressly require consideration or assessment of the prisoner’s risk of harm to others, beyond the suitability of the proposed release address. If a broader assessment of risk of harm to others is anticipated by the Policy, there is no guidance on who should complete the assessment (singular or multi-agency input), when it should be completed, and what factors ought to be considered as part of that assessment.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide communications and training to embed the revised HDC risk-assessment and release-planning requirements.
Verbatim wording from the response “What this means for HDC is that Offender Managers must assess, when completing the Address Checks form, whether there is already in place an adequate plan to manage the offender safely on release. If not, they must identify what steps are needed to put such a plan in place. No release should occur until the plan is in place. In some cases, the plan will exclude the proposed address as the offender cannot be managed safely there, and HDC will be refused. Changes to the HDC Policy Framework will make clear that this approach is required in every case and will be accompanied by communications and training to embed the message going forwards.” Source location 2022-0014-Response-from-Ministry-of-Justice_Published
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 Amend the HDC Policy Framework to require necessary multi-agency information sharing before release decisions.
Verbatim wording from the response “3. The national Home Detention Curfew Policy contains no framework for multi-agency information sharing with regards to the assessment and management of risk for those deemed eligible for early release under the terms of the Policy.
Response:
The HDC Policy Framework will be amended to ensure that the necessary information-sharing takes place before there is a decision to release on HDC.” Source location 2022-0014-Response-from-Ministry-of-Justice_Published
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 an instruction preventing HDC release from segregation unless the governing Governor determines community safety and consults relevant risk-management agencies.
Verbatim wording from the response “Response
I understand and share those concerns. Offenders should not be released on HDC when their current behaviour means that they cannot be safely managed in the community. HM Prisons and Probation Service (HMPPS) is issuing an instruction this week to prison Governors that no prisoner held in a segregation unit may be released on HDC except where the governing Governor themselves has determined that it would safe to do so. In making the decision, the Governor must involve the Community Offender Manager plus key agencies involved in delivering the offender’s risk management plan on release.” Source location 2022-0014-Response-from-Ministry-of-Justice_Published
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 Amend the HDC Policy Framework to require assessment of overall risks and confirmation that an adequate release risk-management plan is in place before HDC release.
Verbatim wording from the response “address. If a broader assessment of risk of harm to others is anticipated by the Policy, there is no guidance on who should complete the assessment (singular or multi-agency input), when it should be completed, and what factors ought to be considered as part of that assessment.
Response:
The HDC Policy Framework will be amended to ensure that consideration for HDC takes into account the risks presented overall, and not just to those at the address.” Source location 2022-0014-Response-from-Ministry-of-Justice_Published
Open published response
5 Jan 2022 Ian Anthony Charles Miller · Prevention of Future Deaths report Gwent
View report summary
Concerns raised 2 Failure to secure and control prisoners’ prescribed medication View source Ineffective randomised checks of prisoners’ medication management 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
Ian Anthony Charles Miller · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Ian Anthony Charles Miller was serving a term at HMP Usk and died by suicide in the prison on 21 September 2019 after being told he could not live at the family home or with his father-in-law, could not have unsupervised contact with his children, and might be homeless. The report raised concerns that prisoners were trading prescribed medication at HMP Usk and that unprescribed medication was being ingested, putting other prisoners’ lives at risk.
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 secure and control prisoners’ prescribed medication
Wider context from the report “1. The management of medication prescribed to prisoners.
At post mortem examination the toxicologist determined that there were a number of drugs in Ian’s blood and urine that he had not been prescribed.
The court was informed that at HMP Usk, all prisoners are required to be capable of managing their own medication . The medications are not kept in a locked facility. The evidence provided clearly indicated that prisoners were trading prescribed medication which had become a form of currency within the prison. Ian’s former cellmate indicated this practice was rife and indeed Ian bought medication from other prisoners. Evidence was heard from the Governor / Head of Safety at HMP Usk who informed the court that he was not aware of this practice, and it appears this was also not known by the prison officers.
The court was informed that there is a system of randomised checks in place within the prison to attempt to determine whether prisoners are appropriately managing their medication, however prisoners have clearly found ways around this.
Whilst the ingestion of unprescribed medication did not contribute to Ian’s death, this practice, if left unchecked, clearly puts the lives of other prisoners at risk in the future.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 randomised checks of prisoners’ medication management
Wider context from the report “1. The management of medication prescribed to prisoners.
At post mortem examination the toxicologist determined that there were a number of drugs in Ian’s blood and urine that he had not been prescribed.
The court was informed that at HMP Usk, all prisoners are required to be capable of managing their own medication. The medications are not kept in a locked facility. The evidence provided clearly indicated that prisoners were trading prescribed medication which had become a form of currency within the prison. Ian’s former cellmate indicated this practice was rife and indeed Ian bought medication from other prisoners. Evidence was heard from the Governor / Head of Safety at HMP Usk who informed the court that he was not aware of this practice, and it appears this was also not known by the prison officers.
The court was informed that there is a system of randomised checks in place within the prison to attempt to determine whether prisoners are appropriately managing their medication, however prisoners have clearly found ways around this.
Whilst the ingestion of unprescribed medication did not contribute to Ian’s death, this practice, if left unchecked, clearly puts the lives of other prisoners at risk in the future.
” Open source report
22 Dec 2021 Mark Castley · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 1 Failure to fully assess recurrent impulsive self-harm risks in post-sentencing situations 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 Castley · 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 Castley died by suicide on 26 June 2019 in St Thomas Hospital after bringing a ████████ into court. The inquest jury identified non-completion of a suicide risk form by the probation officer and non-confiscation of the ████████ by the dock officer as contributing factors. The report raises concern that risks of recurrent impulsive self-harm in the context of sentencing were not fully assessed and that the relevant policy may have required or been interpreted as requiring imminence of risk.
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 fully assess recurrent impulsive self-harm risks in post-sentencing situations
Wider context from the report “The evidence suggests that his risks of recurrent impulsive self harm in situations his ex wife described as “when he is cornered” were not fully assessed as applying to the time after he was being sentenced and if they had been, a notification form might have been completed. Whether this was due to the policy requiring imminence of risk at the time of assessment or being erroneously interpreted so, or whether the projection of imminence arising in a future context was not fully considered , is not clear.
” Open source report
22 Dec 2021 Kyle Nel · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 4 Failure to provide a formal written response to family or friends raising prisoner health or welfare concerns View source Failure of prison security fences to prevent the transfer of drugs and other prohibited materials between prisoners View source Failure to keep a computer record of family or friend concerns and measures taken to address them View source Failure to use a structured approach for responding to family or friend concerns about prisoner health or welfare 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
Kyle Nel · 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
Kyle Nel, a serving prisoner at HMP Guys Marsh, was found unconscious in his cell on 9 June 2018 and was subsequently declared dead after resuscitation attempts. The inquest recorded the medical cause of death as aspiration of gastric contents associated with synthetic cannabinoid (5F-ADB), also known as “Spice”, use, with a conclusion of misadventure. Concerns included the prison’s handling and recording of welfare concerns raised by families and the ability to pass drugs and other prohibited items between prison units through security fences.
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 a formal written response to family or friends raising prisoner health or welfare concerns
Wider context from the report “i) I have concerns that when members of a prisoner’s family or friends contact the prison raising concerns as to the health or welfare of a prisoner, there needs to be structured approach and computer record kept of those concerns, the measures taken to deal with the concerns and a formal written response to the family or friends who have raised those concerns . It is understood that while there are potential security and confidentiality issues that may arise from this process suitable measures should be considered and implemented.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure of prison security fences to prevent the transfer of drugs and other prohibited materials between prisoners
Wider context from the report “ii) The security fences within the prison estate need to be reviewed and consideration urgently given to prevent drugs and other prohibited materials being passed between prisoners through the fences .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 keep a computer record of family or friend concerns and measures taken to address them
Wider context from the report “i) I have concerns that when members of a prisoner’s family or friends contact the prison raising concerns as to the health or welfare of a prisoner, there needs to be structured approach and computer record kept of those concerns, the measures taken to deal with the concerns and a formal written response to the family or friends who have raised those concerns. It is understood that while there are potential security and confidentiality issues that may arise from this process suitable measures should be considered and implemented.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 a structured approach for responding to family or friend concerns about prisoner health or welfare
Wider context from the report “i) I have concerns that when members of a prisoner’s family or friends contact the prison raising concerns as to the health or welfare of a prisoner, there needs to be structured approach and computer record kept of those concerns, the measures taken to deal with the concerns and a formal written response to the family or friends who have raised those concerns. It is understood that while there are potential security and confidentiality issues that may arise from this process suitable measures should be considered and implemented.
” Open source report
30 Nov 2021 Connor Arthur Steven Hout · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 2 Failure to obtain a response from all prisoners during welfare checks View source Lack of clearly understood systems for assuring prisoner wellbeing during or shortly after unlock 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
Connor Arthur Steven Hout · 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
Connor Arthur Steven Hout, aged 24, was found deceased in his prison cell on 10 June 2019 after several brief observations by prison officers during the morning. The report identified that welfare checks did not require officers to obtain a response or engage with prisoners, including those who appeared to be asleep, creating a risk that prisoners in distress or otherwise causing concern could be missed.
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 obtain a response from all prisoners during welfare checks
Wider context from the report “The evidence revealed prison officers are not obtaining, nor did the prison systems require them to obtain, a response from all prisoners during welfare checks . More specifically, during the morning unlock they are not required to, and therefore do not necessarily seek to, obtain a response or otherwise engage with prisoners . In particular, no response is required, and therefore not sought, from prisoners who appear to be asleep in bed , notwithstanding the requirements of PSI 75/2011 (Residential Services).
The PSI sets out the fact that residential prison staff play a key role in spotting any signs of distress and will often be the first to pick up information or signs, and should accordingly engage with prisoners in such a way that facilitates the identification of any concerns or distress.
Further, paragraph 2.3 of the PSI, namely, “Output No. 3 Prisoners are supported and their daily needs are met” states that prisons are required to have, “clearly understood systems in place for staff to assure themselves of the wellbeing of prisoners during or shortly after unlock”.
In the absence of such systems prisoners in distress, or otherwise a cause for concern, may be missed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 understood systems for assuring prisoner wellbeing during or shortly after unlock
Wider context from the report “The evidence revealed prison officers are not obtaining, nor did the prison systems require them to obtain, a response from all prisoners during welfare checks. More specifically, during the morning unlock they are not required to, and therefore do not necessarily seek to, obtain a response or otherwise engage with prisoners. In particular, no response is required, and therefore not sought, from prisoners who appear to be asleep in bed, notwithstanding the requirements of PSI 75/2011 (Residential Services).
The PSI sets out the fact that residential prison staff play a key role in spotting any signs of distress and will often be the first to pick up information or signs, and should accordingly engage with prisoners in such a way that facilitates the identification of any concerns or distress.
Further, paragraph 2.3 of the PSI, namely, “Output No. 3 Prisoners are supported and their daily needs are met” states that prisons are required to have, “clearly understood systems in place for staff to assure themselves of the wellbeing of prisoners during or shortly after unlock” .
In the absence of such systems prisoners in distress, or otherwise a cause for concern, may be missed .
” Open source report
4 Nov 2021 Christian Gary HINKLEY · Prevention of Future Deaths report Mid Kent and Medway
View report summary
Concerns raised 3 Lack of fire-safer cells for prisoners at increased risk of in-cell fire View source Failure of prison fire detection systems to reliably detect in-cell fires within a life-saving timescale View source Unavailability of timely Fire and Rescue Service attendance at prison cells with firefighting equipment 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
Christian Gary HINKLEY · 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
Christian Gary Hinkley, a prisoner at HMP Swaleside, died from smoke inhalation after a fire developed in his barricaded cell during the night of 28–29 July 2019. The report raises concerns that prison fire detection systems could not reliably detect cell fires early enough to allow life-saving action, particularly for prisoners at increased risk, and that installing in-cell detectors across prisons could take years.
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 fire-safer cells for prisoners at increased risk of in-cell fire
Wider context from the report “I am concerned that:
(a) The system of fire detection in HM Prisons is currently inadequate and unsafe. This evidence came from MOJ and CPFSI witnesses and was undisputed.
(b) Whilst there is a plan to install in-cell automatic fire detectors in all prison cells the MOJ estimates that this may take up to 7 years to complete in 35 prisons across England and Wales (and perhaps longer for others).
(c) From the MOJ’s own study in 2007 it is expected that a prisoner in a cell will die within 8 minutes of ignition of an in-cell fire.
(d) There is no reasonable prospect of local Fire & Rescue Service firefighters attending the cell with breathing apparatus and firefighting equipment within that timescale.
(e) As it stands, and until in-cell fire detectors are installed at prisons, there is a significant risk of death from in-cell fires because the current fire detection systems cannot reliably detect a fire within a timescale that will enable life-saving steps to be taken in time.
(f) That risk is further increased for prisoners with a history of suicide/self-harm, barricading and/or arson.
(g) The Chief Inspector of the CPFSI tells us that simple measures could be taken to reduce the risk of death by fire in prison, namely adding in-cell fire detectors to a small number of cells in each wing for prisoners (a) on an ACCT, (b) with a history of barricading, (c) with a history of prison fire-setting or (d) with a history of arson, and placing such prisoners in those fire-safer cells.
Accordingly, this situation should be reviewed and consideration given as to whether any steps should be taken to reduce the risk of death by cell fires in prisons (as an interim measure before in-cell detection systems are installed across the prison estate). In particular, the suggestion of the Chief Inspector of the CPFSI – highlighted in bold above – should be considered carefully.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure of prison fire detection systems to reliably detect in-cell fires within a life-saving timescale
Wider context from the report “I am concerned that:
(a) The system of fire detection in HM Prisons is currently inadequate and unsafe . This evidence came from MOJ and CPFSI witnesses and was undisputed.
(b) Whilst there is a plan to install in-cell automatic fire detectors in all prison cells the MOJ estimates that this may take up to 7 years to complete in 35 prisons across England and Wales (and perhaps longer for others) .
(c) From the MOJ’s own study in 2007 it is expected that a prisoner in a cell will die within 8 minutes of ignition of an in-cell fire.
(d) There is no reasonable prospect of local Fire & Rescue Service firefighters attending the cell with breathing apparatus and firefighting equipment within that timescale.
(e) As it stands, and until in-cell fire detectors are installed at prisons, there is a significant risk of death from in-cell fires because the current fire detection systems cannot reliably detect a fire within a timescale that will enable life-saving steps to be taken in time .
(f) That risk is further increased for prisoners with a history of suicide/self-harm, barricading and/or arson.
(g) The Chief Inspector of the CPFSI tells us that simple measures could be taken to reduce the risk of death by fire in prison, namely adding in-cell fire detectors to a small number of cells in each wing for prisoners (a) on an ACCT, (b) with a history of barricading, (c) with a history of prison fire-setting or (d) with a history of arson, and placing such prisoners in those fire-safer cells.
Accordingly, this situation should be reviewed and consideration given as to whether any steps should be taken to reduce the risk of death by cell fires in prisons (as an interim measure before in-cell detection systems are installed across the prison estate). In particular, the suggestion of the Chief Inspector of the CPFSI – highlighted in bold above – should be considered carefully.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 timely Fire and Rescue Service attendance at prison cells with firefighting equipment
Wider context from the report “I am concerned that:
(a) The system of fire detection in HM Prisons is currently inadequate and unsafe. This evidence came from MOJ and CPFSI witnesses and was undisputed.
(b) Whilst there is a plan to install in-cell automatic fire detectors in all prison cells the MOJ estimates that this may take up to 7 years to complete in 35 prisons across England and Wales (and perhaps longer for others).
(c) From the MOJ’s own study in 2007 it is expected that a prisoner in a cell will die within 8 minutes of ignition of an in-cell fire.
(d) There is no reasonable prospect of local Fire & Rescue Service firefighters attending the cell with breathing apparatus and firefighting equipment within that timescale.
(e) As it stands, and until in-cell fire detectors are installed at prisons, there is a significant risk of death from in-cell fires because the current fire detection systems cannot reliably detect a fire within a timescale that will enable life-saving steps to be taken in time.
(f) That risk is further increased for prisoners with a history of suicide/self-harm, barricading and/or arson.
(g) The Chief Inspector of the CPFSI tells us that simple measures could be taken to reduce the risk of death by fire in prison, namely adding in-cell fire detectors to a small number of cells in each wing for prisoners (a) on an ACCT, (b) with a history of barricading, (c) with a history of prison fire-setting or (d) with a history of arson, and placing such prisoners in those fire-safer cells.
Accordingly, this situation should be reviewed and consideration given as to whether any steps should be taken to reduce the risk of death by cell fires in prisons (as an interim measure before in-cell detection systems are installed across the prison estate). In particular, the suggestion of the Chief Inspector of the CPFSI – highlighted in bold above – should be considered carefully.
” Open source report
3 Nov 2021 Saskia Jones and 2 others · Prevention of Future Deaths report London City
View report summary
Concerns raised 24 Failure to inform MAPPA panels about regularity and form of overt offender-management contact View source Insufficient consideration of extremist offenders’ dishonest self-presentation View source Failure to share and consider counter-terrorism police intelligence in MAPPA management View source Failure to properly reason and record offender-manager licence-condition approvals View source Failure to provide MAPPA panels important prison-history information View source Failure to provide MAPPA panels direct input from the preparing forensic psychologist View source Failure to communicate between offender managers and event organisers before extremist offenders attend events View source Insufficient risk assessment and management for prison higher education programmes involving post-release offender contact View source Sudden disruption of DDP mentoring arrangements View source Sudden loss of supervised internet access for employment searches View source Failure to complete the full structured assessment before changing an OASys risk rating View source Failure to properly consider security-sensitive information in MAPPA decisions View source Lack of precautionary search capability for terrorist offenders on licence View source Failure to detect Class A drug use by terrorist offenders on licence View source Unavailability of offender risk-profile information to prison-based higher education providers View source Failure to ensure all MAPPA meeting attendees receive meeting minutes View source Failure to ensure direct forensic psychologist involvement in ERG 22+ assessment reports View source Failure to assess risks of continuing close contact between serious offenders and young students View source Excessive reliance on compliance in management of extremist offenders View source Failure to communicate high-risk event attendance to host venues View source Failure to directly address risks when approving licence-condition changes View source Lack of formal risk assessment for higher education events held outside university premises View source Failure of MAPPA panels to conduct clearly reasoned discussion and decision-making on licence-condition changes View source Failure to record proper rationale for changes to OASys risk ratings View source See 21 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 17
Action
Develop and consolidate the Licence Conditions Policy Framework, including recording and partner-engagement requirements for licence decisions.
Stated plannedThe respondent said that this action was planned when they made their response on 3 November 2021. View source
Action
Amend the MAPPA document set and meeting template to retain prison information and record intelligence, ERG conclusions, and risk factors.
Stated plannedThe respondent said that this action was planned when they made their response on 3 November 2021. View source
Action
Introduce and operate an ERG standard operating procedure covering assessment completion, independence, progression points, and assessor responsibilities.
Stated completedThe respondent said that this action was complete when they made their response on 3 November 2021. View source
Action
Strengthen MAPPA guidance requiring police to report contact frequency and outcomes and consider panel recommendations.
Stated plannedThe respondent said that this action was planned when they made their response on 3 November 2021. View source
Action
Deliver training and bespoke guidance promoting professional curiosity and balanced assessment of extremist offenders.
Stated completedThe respondent said that this action was complete when they made their response on 3 November 2021. View source
Action
Update MAPPA statutory guidance to require forensic psychologists to attend meetings and present ERG assessments, including Level 3 and core group meetings.
Stated plannedThe respondent said that this action was planned when they made their response on 3 November 2021. View source
Action
Amend and reissue MAPPA guidance with an updated minutes template and guidance on digitally recording meetings.
Stated plannedThe respondent said that this action was planned when they made their response on 3 November 2021. View source
Action
Implement guidance requiring licence variations or relaxations to use an up-to-date reviewed risk assessment.
Stated completedThe respondent said that this action was complete when they made their response on 3 November 2021. View source
Action
Assess how to make best use of drug-testing capabilities for offenders on licence.
Stated in progressThe respondent said that this action was in progress when they made their response on 3 November 2021. View source
Action
Strengthen MAPPA guidance to require prompt secure distribution of minutes, receipt confirmation, and confirmation that previous minutes were read.
Stated plannedThe respondent said that this action was planned when they made their response on 3 November 2021. View source
Action
Publish guidance on licence variation and authorisation, requiring decisions and rationales to be recorded on NDelius.
Stated completedThe respondent said that this action was complete when they made their response on 3 November 2021. View source
Action
Operate the covert-overt bridge framework to identify, review, reveal, and disclose sensitive intelligence for MAPPA risk-management decisions.
Stated completedThe respondent said that this action was complete when they made their response on 3 November 2021. View source
Action
Revise MAPPA guidance to require consideration of disclosure to relevant event hosts and clearer recording of disclosure decisions.
Stated plannedThe respondent said that this action was planned when they made their response on 3 November 2021. View source
Action
Provide reduced NSD caseloads and senior practitioner oversight through countersigning and regular supervision.
Stated completedThe respondent said that this action was complete when they made their response on 3 November 2021. View source
Action
Design and consult on a framework defining prison and university responsibilities, risk assessment, and sharing of offender risk information.
Stated in progressThe respondent said that this action was in progress when they made their response on 3 November 2021. View source
Action
Issue staff instructions requiring formal risk assessment before recorded risk levels are reduced.
Stated plannedThe respondent said that this action was planned when they made their response on 3 November 2021. View source
Action
Create a licence condition requiring terrorist offenders to submit to personal searches.
Stated plannedThe respondent said that this action was planned when they made their response on 3 November 2021. View source See 14 more actions
×
AI-generated summary
Saskia Jones 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
On 29 November 2019, Usman Khan carried out a terrorist attack at Fishmongers’ Hall, fatally stabbing Saskia Jones and Jack Merritt before being fatally shot by firearms officers on London Bridge. The report raised concerns about risk assessment and communication for events involving high-risk offenders, and about the assessment, information-sharing, supervision and management of terrorist offenders released into the community.
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 inform MAPPA panels about regularity and form of overt offender-management contact
Wider context from the report “The facts of this case give cause for concern that MAPPA panels responsible for managing terrorist offenders may be unaware of the regularity and form of contact with police officers responsible for overt offender management .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 extremist offenders’ dishonest self-presentation
Wider context from the report “The facts of this case give rise to concern that probation officers may give insufficient regard to instances of dishonesty in self-presentation by extremist offenders .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to share and consider counter-terrorism police intelligence in MAPPA management
Wider context from the report “This case gives cause for concern that counter-terrorism police may be in possession of intelligence or information which may be useful to the management of an offender by the MAPPA panel, but that such intelligence or information may not be brought to the knowledge of or taken into account by MAPPA agencies .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 properly reason and record offender-manager licence-condition approvals
Wider context from the report “This case gives rise to concern that offender managers may take significant decisions to give approvals under licence conditions without those decisions being properly reasoned and recorded .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to provide MAPPA panels important prison-history information
Wider context from the report “The facts of this case give cause for concern that some members of MAPPA panels responsible for managing extremist offenders may not be aware of important information from the offender’s time in prison .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to provide MAPPA panels direct input from the preparing forensic psychologist
Wider context from the report “It is a matter for concern that MAPPA panels managing even the most serious offenders may not have the benefit of hearing directly from a forensic psychologist who has prepared an ERG report shortly prior to the offender’s release .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 between offender managers and event organisers before extremist offenders attend events
Wider context from the report “This case gives rise to concern that an extremist offender may be permitted to attend an event or venue without there having been proper communication between the probation and police officers responsible for managing the offender and the event organisers and/or venue hosts .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 risk assessment and management for prison higher education programmes involving post-release offender contact
Wider context from the report “Consideration should be given to whether further measures of risk assessment and management can be introduced for any higher education programmes running in prisons which involve continued contact with offenders after their release into the community .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Sudden disruption of DDP mentoring arrangements
Wider context from the report “This case gives rise to concern that mentoring arrangements under the DDP could be disrupted suddenly in the case of a person whose risk of re-engaging in extremism was known to be related to social isolation. It also gives rise to concern that an offender could be suddenly deprived of the means to use the internet under supervision to search for work.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Sudden loss of supervised internet access for employment searches
Wider context from the report “This case gives rise to concern that mentoring arrangements under the DDP could be disrupted suddenly in the case of a person whose risk of re-engaging in extremism was known to be related to social isolation. It also gives rise to concern that an offender could be suddenly deprived of the means to use the internet under supervision to search for work .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 the full structured assessment before changing an OASys risk rating
Wider context from the report “The facts of this case give rise to concern that an OASys risk rating for an offender may be changed without the offender manager conducting the full assessment exercise (using the structured form) and that the change may be recorded without proper rationale.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 properly consider security-sensitive information in MAPPA decisions
Wider context from the report “The facts of this case give cause for concern that security sensitive information may not be properly taken into account in decision-making by MAPPA panels concerning the management of terrorist offenders.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 precautionary search capability for terrorist offenders on licence
Wider context from the report “The facts of this case gave cause for concern that those involved in managing terrorist offenders on licence may lack a valuable means of addressing risks they pose, namely an ability to carry out a search on a precautionary basis .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 detect Class A drug use by terrorist offenders on licence
Wider context from the report “The facts of this case give cause for concern that a terrorist offender on licence, who was subject both to strict licence conditions and to a priority investigation, could obtain and use Class A drugs without that being detected .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 offender risk-profile information to prison-based higher education providers
Wider context from the report “It is a matter of concern that Learning Together could operate courses in prisons in the way it did without being given information about the risk profiles of offenders joining courses .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 all MAPPA meeting attendees receive meeting minutes
Wider context from the report “Based on the evidence in this case, there is cause for concern that effective procedures are not in place to ensure that all MAPPA meeting attendees receive meeting minutes .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 direct forensic psychologist involvement in ERG 22+ assessment reports
Wider context from the report “Notwithstanding the measures which the NPS has put in place since the attack, there remains cause for concern that ERG 22+ assessment reports may be prepared by a CTPO without the direct involvement of a forensic psychologist .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 risks of continuing close contact between serious offenders and young students
Wider context from the report “It is a matter of concern that focussed consideration was not given to the risks of serious offenders being placed in close and continuing contact with young students .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Excessive reliance on compliance in management of extremist offenders
Wider context from the report “Based on the facts of this case, there is cause for concern that probation officers may attach excessive weight in their management of extremist offenders to “compliance” (i.e. absence of evidence of breach of licence conditions and police behaviour).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate high-risk event attendance to host venues
Wider context from the report “It is a matter of concern that a major event could be held by a University at a livery company hall in London without clear communication of the fact that it would be attended by serving and recently released serious offenders .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 directly address risks when approving licence-condition changes
Wider context from the report “This case gives cause for concern that an offender manager and/or MAPPA panel participants could approve a permission, variation or relaxation in relation to a licence condition without directly addressing the potential risks involved .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Lack of formal risk assessment for higher education events held outside university premises
Wider context from the report “It is a matter of concern that there was no such risk assessment for Learning Together events as set out above.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 MAPPA panels to conduct clearly reasoned discussion and decision-making on licence-condition changes
Wider context from the report “The facts of this case give rise to concern that important decisions on approvals, variations and relaxations in relation to licence conditions may be taken without clearly reasoned discussion and decision-making in MAPPA panels .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to record proper rationale for changes to OASys risk ratings
Wider context from the report “The facts of this case give rise to concern that an OASys risk rating for an offender may be changed without the offender manager conducting the full assessment exercise (using the structured form) and that the change may be recorded without proper rationale .
” 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 Develop and consolidate the Licence Conditions Policy Framework, including recording and partner-engagement requirements for licence decisions.
Verbatim wording from the response “• We have published guidance on Licence Variation and Authorisation. A draft version of the Licence Conditions Policy Framework is currently being considered by stakeholders and will update and consolidate all changes into policy following the Royal Assent for the Police, Crime, Sentencing and Courts Bill, expected in February 2022. This Framework will set out expectations of probation and prison staff in relation to both changes in licence conditions and the specific authorisation which must be obtained before an offender is permitted to undertake an activity which would otherwise be prohibited by the licence. One of the key policy changes will be the introduction of a requirement that practitioners ensure that any discussions and decisions around whether or not to vary a licence condition or authorise activity outside of a condition are recorded in case notes on NDelius.” Source location 2021-0362-Response-from-MoJ_Published
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 Amend the MAPPA document set and meeting template to retain prison information and record intelligence, ERG conclusions, and risk factors.
Verbatim wording from the response “• We will amend the document set to ensure that key information from the MAPPA F is retained for future meetings post release from custody. The new MAPPA meeting template will include a section for key up-to-date intelligence, key conclusions of the most recent ERG assessment and provide for a clear record of risk factors.” Source location 2021-0362-Response-from-MoJ_Published
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 an ERG standard operating procedure covering assessment completion, independence, progression points, and assessor responsibilities.
Verbatim wording from the response “• We have strengthened our current operational processes with the introduction of a Standard Operating procedure (SOP), drawing upon several guiding principles to provide all Extremism Risk Guidance trained assessors, supervisors and staff involved in the management of terrorist cases with guidance regarding the completion of ERGs in HMPPS.” Source location 2021-0362-Response-from-MoJ_Published
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 Strengthen MAPPA guidance requiring police to report contact frequency and outcomes and consider panel recommendations.
Verbatim wording from the response “• We will strengthen the MAPPA meetings chapter of the statutory guidance to put beyond doubt the expectation that police share full information about regularity and outcomes of any contact and consider recommendations of the panel.” Source location 2021-0362-Response-from-MoJ_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver training and bespoke guidance promoting professional curiosity and balanced assessment of extremist offenders.
Verbatim wording from the response “• The OASys Guidance for TACT and TACT related offenders, dated April 2018 stated: “Extremist offenders can have a well-rehearsed script in relation to their offending and may not be open or candid about their thinking, associations and affiliations. They may also have been advised by extremist associates not to respond to professionals”. We encourage report authors and case managers to take a triangulation approach whereby they consider a range of sources including the offender's account to understand the risk. In addition, the core group approach will guard against conditioning and manipulation as the group will provide check and balances for all decisions.” Source location 2021-0362-Response-from-MoJ_Published
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 MAPPA statutory guidance to require forensic psychologists to attend meetings and present ERG assessments, including Level 3 and core group meetings.
Verbatim wording from the response “• We will update the MAPPA statutory guidance by April 2022, to make it a requirement that psychologists attend MAPPA meetings – and, specifically, to require them to be invited to present their ERG assessment to the MAPPA meeting. The updates will form part of a wider revision of the chapter on meetings in the MAPPA Guidance.” Source location 2021-0362-Response-from-MoJ_Published
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 Amend and reissue MAPPA guidance with an updated minutes template and guidance on digitally recording meetings.
Verbatim wording from the response “• Relevant parts of the statutory MAPPA Guidance will be amended and re-issued in April 2022, with an updated template for minutes of MAPPA meetings and guidance of the digital recording of MAPPA meetings.” Source location 2021-0362-Response-from-MoJ_Published
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 guidance requiring licence variations or relaxations to use an up-to-date reviewed risk assessment.
Verbatim wording from the response “• New guidance was introduced in December 2021 which ensures that decisions to vary or relax licence conditions must always be subject to an up-to-date and reviewed” Source location 2021-0362-Response-from-MoJ_Published
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 Assess how to make best use of drug-testing capabilities for offenders on licence.
Verbatim wording from the response “• We are considering this recommendation to ensure that we are making best use of our drug testing abilities.” Source location 2021-0362-Response-from-MoJ_Published
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 Strengthen MAPPA guidance to require prompt secure distribution of minutes, receipt confirmation, and confirmation that previous minutes were read.
Verbatim wording from the response “We are strengthening the guidance to set a clear MAPPA standard for the prompt distribution of MAPPA minutes via secure email and confirmation of accuracy of minutes. Revisions” Source location 2021-0362-Response-from-MoJ_Published
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 on licence variation and authorisation, requiring decisions and rationales to be recorded on NDelius.
Verbatim wording from the response “• We have published guidance on Licence Variation and Authorisation. A draft version of the Licence Conditions Policy Framework is currently being considered by stakeholders and will update and consolidate all changes into policy following the Royal Assent for the Police, Crime, Sentencing and Courts Bill, expected in February 2022. This Framework will set out expectations of probation and prison staff in relation to both changes in licence conditions and the specific authorisation which must be obtained before an offender is permitted to undertake an activity which would otherwise be prohibited by the licence. One of the key policy changes will be the introduction of a requirement that practitioners ensure that any discussions and decisions around whether or not to vary a licence condition or authorise activity outside of a condition are recorded in case notes on NDelius.” Source location 2021-0362-Response-from-MoJ_Published
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 Operate the covert-overt bridge framework to identify, review, reveal, and disclose sensitive intelligence for MAPPA risk-management decisions.
Verbatim wording from the response “• The Joint Counter-Terrorism Prisons and Probation Hub (JCTPPH) is a collaboration between HMPS, CTP and the Security Service to ensure the right information gets to the right place at the right time. Launched in 2021, a major focus has been the development and operationalisation of a covert-overt bridge framework. This provides an effective, safe, process through which sensitive intelligence can be revealed and subsequently, appropriately, disclosed to support defensible decision-making regarding risk management. Originally focused on supporting better disclosure into the Parole Board, the framework is now being applied to MAPPA where the bridge has been tested using information previously only known to the Security Service.” Source location 2021-0362-Response-from-MoJ_Published
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 Revise MAPPA guidance to require consideration of disclosure to relevant event hosts and clearer recording of disclosure decisions.
Verbatim wording from the response “• MAPPA guidance requires disclosure to be considered at every discussion, and disclosure will be made where the MAPPA agencies conclude that the offender’s risk may be effectively managed only by making disclosure to specified individuals or bodies. We will revise the guidance, so that it states explicitly that consideration must be given to disclosure to an event host organiser, where relevant, which would facilitate wider discussion outside MAPPA around event security. The MAPPA minutes template is being updated so that decisions on disclosure are more clearly recorded.” Source location 2021-0362-Response-from-MoJ_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide reduced NSD caseloads and senior practitioner oversight through countersigning and regular supervision.
Verbatim wording from the response “• The reduced caseloads in NSD enable Senior Probation Practitioners (SPPs) to provide greater management oversight of cases. SPPs countersign all OASys assessments and provide regular supervision for Probation Practitioners (PPs) creating opportunities to review cases and ensure PPs are taking a balanced view.” Source location 2021-0362-Response-from-MoJ_Published
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 Design and consult on a framework defining prison and university responsibilities, risk assessment, and sharing of offender risk information.
Verbatim wording from the response “• Ahead of any decision to restart we are designing a new framework to clearly define the roles and responsibilities of prisons and universities when they work in partnership to deliver learning where students study alongside serving prisoners or those released on licence. This will include guidance setting out the responsibility for risk assessment and the circumstances in which risk information will be shared. We expect to complete initial work in January 2022 and will then consult with prisons and universities to ensure it meets requirements with the ambition of having it in place by April 2022.” Source location 2021-0362-Response-from-MoJ_Published
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 staff instructions requiring formal risk assessment before recorded risk levels are reduced.
Verbatim wording from the response “• We will issue an instruction to staff by January 2022 that sets out the requirement that changes in recorded risk level must be informed by completing a formal risk assessment and may never be reduced without such an assessment regardless of wider resource constraints.” Source location 2021-0362-Response-from-MoJ_Published
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 a licence condition requiring terrorist offenders to submit to personal searches.
Verbatim wording from the response “• The Police, Crime, Sentencing and Courts Bill provides a power enables the Police to make a personal search of a terrorist offender on licence provided their licence includes a search condition. It forms one of several measures included in the Bill in response to ████████ independent review of MAPPA and the management of terrorist offenders. This new power will enable the search to be conducted without reasonable suspicion and outside exceptional circumstances. For the police to use this power, we will create a new licence condition that requires offenders to submit to a personal search.” Source location 2021-0362-Response-from-MoJ_Published
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 A blended model using forensic psychologists and counter-terrorism probation specialists is considered the best model for community ERG assessments.
Verbatim wording from the response “• We accept option (b) of this recommendation.” Source location 2021-0362-Response-from-MoJ_Published
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 MAPPA does not make final decisions to apply, remove or authorise licence conditions; those decisions are recorded on case management systems.
Verbatim wording from the response “• The final decision for applying/removing/authorising a licence condition is not made by MAPPA: these decisions will be recorded on case management systems, including where stakeholders have been involved including MAPPA and the Police. The new model introduced by the NSD will enable greater oversight of cases and decision-making by Senior Managers. Management oversight will be monitored through performance and quality assurance measures.” Source location 2021-0362-Response-from-MoJ_Published
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 Drug-testing licence conditions must satisfy necessity and proportionality requirements and specified statutory criteria, limiting wider testing.
Verbatim wording from the response “• Currently, a licence condition to comply with drug testing is considered in all cases where substance abuse is linked to the index offence. All licence conditions must meet the ‘necessary and proportionate’ test and current policy (PI 2014 32) states that to impose a drug testing condition/requirement:” Source location 2021-0362-Response-from-MoJ_Published
Open published response
22 Oct 2021 Anthony John Larcher · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 5 Failure of SystmOne to make vital prison healthcare information readily identifiable View source Failure to identify prisoners’ health information during large-cohort reception View source Lack of observations and welfare checks for prisoners found under the influence of psychoactive substances View source Lack of healthcare staff attendance at ACCT reviews View source Lack of 24-hour healthcare across the prison estate View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Anthony John Larcher · 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 21 March 2018, Anthony John Larcher, a serving prisoner at HMP Guys Marsh, was found in his cell. The report identifies concerns about monitoring prisoners under the influence of psychoactive substances, the lack of round-the-clock healthcare, healthcare involvement in ACCT reviews, the accessibility of medical information, and the reception of prisoners arriving in large cohorts.
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 SystmOne to make vital prison healthcare information readily identifiable
Wider context from the report “iv. I am concerned that vital information contained within a prisoner’s medical health records stored on SystmOne, could be missed due to fact the software is more adapted to GP practice than prison healthcare . This could result in a future death and I request consideration is given to adapting SystmOne for better use in prisons to ensure information, especially where there are complex care needs, is easily assessable and highlighted to avoid crucial information regarding a patient’s care and safety being missed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to identify prisoners’ health information during large-cohort reception
Wider context from the report “v. I have concerns with the movement of prisoners around the prison estate in large cohorts as it could result in information regarding a prisoner’s health not being identified which could result in a lack of healthcare provision to the prisoner which could result in a future death. I therefore request that consideration be given to the review of the processes when large cohorts are received at prisons and the resources available to prison and healthcare staff prior to the arrival of the prisoner and during the progression of the prisoners through the reception process.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Lack of observations and welfare checks for prisoners found under the influence of psychoactive substances
Wider context from the report “i. There could be future deaths across the prison estate nationally due to a lack of observations and welfare checks upon prisoners who are found under the influence of Spice and I request consideration be given to the rolling out of the local processes adopted at HMP Guys Marsh, nationally. This includes the roll out of their Welfare Checks Policy, the Persistent Psychoactive Substances Intervention Plan (PPSIP) and the Custodial Officer Intermediate Life Support initiative (COILS).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 healthcare staff attendance at ACCT reviews
Wider context from the report “iii. I have concerns that future deaths could occur due to the lack of attendance of healthcare staff at ACCT reviews, especially where the ACCT is closed . I request that consideration is given to providing guidance nationally by way of a safety bulletin or an update to the ACCT version 6 guidance and in the new PSI to be released in the future on the policy on management of prisoners at risk of harm to self, to others and from others, ensuring the attendance of healthcare staff at all ACCT reviews.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 24-hour healthcare across the prison estate
Wider context from the report “ii. I have concerns that future deaths could occur due to the lack of 24 hour healthcare across the prison estate . I would therefore request consideration be given to the provision of healthcare to all prisons 24 hours a day, 7 days a week.
” Open source report
30 Sep 2021 Stephen David COPE · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 2 Premature closure of ACCTs for newly transferred prisoners before sufficient review, assessment and communication View source ACCT closure criteria being vulnerable to manipulation through two negative prisoner responses 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 David COPE · 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 David Cope died by suspension in his own cell block at Belmarsh prison on 18 November 2019. The principal concern was the transfer and review of prisoners on an ACCT, particularly the closure of an ACCT shortly after a prisoner’s transfer before support services had sufficient time to assess and communicate about them.
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 Premature closure of ACCTs for newly transferred prisoners before sufficient review, assessment and communication
Wider context from the report “(1) The transfer and review of prisoners on an ACCT.
I am concerned in relation to the ability of any Prison to close an ACCT, with the attendance of 2 individuals (a prison and health care staff), after a short period of time on a newly transferred inmate (i.e. to a new prison) before anyone has had the time to review and assess him or her .
For ACCTs created on current inmates within an establishment, who are known to staff, I do not see that as an issue, they would already have an existing knowledge and relationship and indeed would have been the originator of the ACCT in any event.
However, for new prisoners, who have arrived from another prison establishment with an open ACCT on their record, I consider the ability to remove that individual from the ACCT, within a short period of time, does raise issues in respect of the knowledge and understanding of that individual and the ability of various agencies, within the prison, to have had time to review and communicate between themselves, about that individual .
The provision of in effect 2 ‘no’ answers by a prisoner, is a potentially easy way of coming off an ACCT, which is there for their support and well-being, and I would suggest, given to easy manipulation
I raise the issue as to whether there should be, for example, a set review period (e.g. 7 days) which allows time for the support services to meet with and interview the transferred inmate, interact, and then make a decision about and with the newly transferred prisoner on the ACCT before such an ACCT is closed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation ACCT closure criteria being vulnerable to manipulation through two negative prisoner responses
Wider context from the report “(1) The transfer and review of prisoners on an ACCT.
I am concerned in relation to the ability of any Prison to close an ACCT, with the attendance of 2 individuals (a prison and health care staff), after a short period of time on a newly transferred inmate (i.e. to a new prison) before anyone has had the time to review and assess him or her.
For ACCTs created on current inmates within an establishment, who are known to staff, I do not see that as an issue, they would already have an existing knowledge and relationship and indeed would have been the originator of the ACCT in any event.
However, for new prisoners, who have arrived from another prison establishment with an open ACCT on their record, I consider the ability to remove that individual from the ACCT, within a short period of time, does raise issues in respect of the knowledge and understanding of that individual and the ability of various agencies, within the prison, to have had time to review and communicate between themselves, about that individual.
The provision of in effect 2 ‘no’ answers by a prisoner, is a potentially easy way of coming off an ACCT , which is there for their support and well-being, and I would suggest, given to easy manipulation
I raise the issue as to whether there should be, for example, a set review period (e.g. 7 days) which allows time for the support services to meet with and interview the transferred inmate, interact, and then make a decision about and with the newly transferred prisoner on the ACCT before such an ACCT is closed.
” Open source report
3 Aug 2021 Emma Day · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 11 Failure to identify all children when sharing risk information View source Failure to record the duration and conditions of protective orders View source Failure to require escalation of domestic-violence concerns beyond immediate risk View source Failure to include the Non-Molestation Order in the Merlin Report View source Lack of safety netting for escalation of risk View source Inadequate caseworker training on the wider domestic-violence risk context View source Lack of guidance on accepting a caller’s assessment of domestic-violence risk View source Lack of a procedure for responding to threats and passing information to other authorities View source Lack of a system for direct entry of protective orders on the Police National Computer View source Failure of case-record access and handover of key domestic-violence risk information View source Failure to hold or know protective-order conditions and arrest powers View source See 8 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Emma 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
Emma Day died in the street on 26 May 2017 from multiple stab wounds and was found to have been unlawfully killed. The report describes a history of domestic violence, coercive and controlling behaviour, threats to her life and protective orders that had expired shortly before her murder. Principal concerns included failures to share and record risk information, inadequate domestic-violence training and guidance, and a system failure in handling reports of domestic violence within the Child Maintenance Service.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to identify all children when sharing risk information
Wider context from the report “3. The Metropolitan Police Service did not mention the Non-Molestation Order in the Merlin Report, and when shared with Lambeth CSC only one of the children was mentioned .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to record the duration and conditions of protective orders
Wider context from the report “1. The Gaia Centre did not record the length or conditions of either the Non-Molestation Order or the Prohibited Steps Order , nor did there appear to be any safety netting if the situation escalated.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to require escalation of domestic-violence concerns beyond immediate risk
Wider context from the report “d) A caseworker who learnt from a caller of domestic violence was only required to escalate for consideration of signposting or reporting to police if there was an immediate risk of violence , not necessarily if the worker was concerned or an immediate risk was likely to eventuate in the future , in particular on reapplying for maintenance.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 include the Non-Molestation Order in the Merlin Report
Wider context from the report “3. The Metropolitan Police Service did not mention the Non-Molestation Order in the Merlin Report , and when shared with Lambeth CSC only one of the children was mentioned.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 safety netting for escalation of risk
Wider context from the report “1. The Gaia Centre did not record the length or conditions of either the Non-Molestation Order or the Prohibited Steps Order, nor did there appear to be any safety netting if the situation escalated .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Inadequate caseworker training on the wider domestic-violence risk context
Wider context from the report “b) Training of caseworkers at the time on domestic violence was focused on domestic violence as a criterion to grant waiver of the fee and did not provide information about the wider definition, the reluctance to self-declare or the available services to be signposted .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 accepting a caller’s assessment of domestic-violence risk
Wider context from the report “e) Nevertheless in relation to 16th May, Ms Lilley expected case workers to pick up the degree of risk from a report of past threat to kill and escalate and Mr Gilchrist thought the response of the case worker inadequate, as there was a specific request to continue the maintenance claim in the knowledge of a specific threat. But the guidance at the time was silent as to whether to accept the caller’s assessment of risk . I concluded that staff would likely be uncertain of their duties .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 procedure for responding to threats and passing information to other authorities
Wider context from the report “f) Asked about the Domestic Homicide Report’s reference to systemic issues, Mr Gilchrist’s own words were that in May 2017 is where the system fell down. There should be a threat procedure and how to initiate it and pass information to other authorities
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 system for direct entry of protective orders on the Police National Computer
Wider context from the report “4. The Domestic Homicide Review recommended (R24) that the Home Office work with the Ministry of Justice to implement a system whereby protective orders can be input directly to the Police National Computer . It was not clear whether all State bodies that needed to were able to make entries themselves on the Police National Computer Conflicting evidence was heard, but one police officer stated that R24 had not been adopted , and to do so would be welcomed by other agencies and that without this change there might be missed opportunities to save lives .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 case-record access and handover of key domestic-violence risk information
Wider context from the report “The Coroner concluded that there was a system failure in Child Maintenance Service of Department of Work and Pensions in handling reports of domestic violence.
a) There was no mutual access of case records or system of handing on key risk information between CMO and CMS and so the eliciting of domestic violence risks relies upon repeated self-reporting by a victim .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to hold or know protective-order conditions and arrest powers
Wider context from the report “2. Lambeth Children’s Social Care (CSC) had no copy nor knew conditions of either Order, nor that there was a power of arrest . There seem to be steps taken by the CSC to consider action to mitigate the risk posed by the perpetrator in light of these Orders.
” Open source report
16 Jul 2021 Miss Joanna Daly · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 1 Absence of specific guidance for conducting welfare checks in the First Night Centre 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
Miss Joanna Daly · 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
Miss Joanna Daly was found unresponsive in her cell at HMP New Hall on the morning of 2 June 2019, and her death was confirmed. The inquest jury found that healthcare checks in the First Night Centre had not been carried out adequately and that this could have contributed to her death. The report raises concern about the absence of specific guidance for welfare checks of vulnerable prisoners in the First Night Centre.
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 specific guidance for conducting welfare checks in the First Night Centre
Wider context from the report “During the course of the Inquest, the matter of checks undertaken by healthcare staff on prisoners resident for their first night in the prison's First Night Centre was heard in evidence. The jury found that no guidance as to how such checks were to be conducted had been provided to the staff undertaking the checks , and that it was possible that this contributed to Joanna's death.
Since Joanna's death, checks within HMP New Hall have been undertaken whereby welfare checks undertaken at the First Night Centre are now completed by prison staff. The new arrangements have been in place since October 2020.
Whilst evidence was provided of the key times at which such checks are undertaken, it became apparent that there was no specific guidance provided to prison staff to explain what was required to be undertaken during a welfare check . The particular vulnerability of prisoners resident on the First Night Centre is the reason for such checks.
I am concerned about the absence of any specific guidance , in view of the findings of the jury in relation to the night checks that were previously undertaken by the healthcare staff at the time of Joanna's death.
This could impact upon the quality of the welfare checks that are now undertaken by the prison staff, in the context of the First Night Centre where prisoners may be particularly vulnerable. I am under a duty to report this matter upon consideration of the evidence as provided to the court.
” 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