22 Jun 2021 Serena Nicolle · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 1 Use of an unreliable chest/abdomen movement observation method for checking breathing through cell door hatches 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
Serena Nicolle · 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
Serena Nicolle died in her cell at HMP Bronzefield on 3 September 2018 from ventricular arrhythmia in the context of hypertensive heart disease, with diabetes, sleep apnoea, obesity and stress also recorded. Two prison staff members incorrectly assessed her as breathing after observing movement through the cell hatch, and the Coroner was concerned that this standard procedure may be an unreliable way to check breathing and could create a risk of future deaths.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Use of an unreliable chest/abdomen movement observation method for checking breathing through cell door hatches
Wider context from the report “During the course of the inquest the court heard evidence that observing the movement of an individual’s chest and abdomen through a cell hatch is a standard procedure for checking whether they are breathing , in circumstances where they are not otherwise moving or responding to prison staff. The court heard that this is the position across the prison estate and is not limited to HMP Bronzefield.
The court also heard evidence from expert witness Dr ████████, a Consultant Cardiologist, who stated that in his opinion it is very difficult to assess whether somebody is breathing or not by looking for movement in the chest/abdomen from a distance .
The Coroner is concerned that on 3 September 2018 two members of prison staff assessed that Mrs Nicolle was breathing when she was in fact deceased, and that in doing so they followed standard procedures which are in place across the prison estate.
Whilst these errors did not contribute to Mrs Nicolle’s death, the Coroner is concerned that were similar errors to occur in the future, it would present a risk of future deaths, particularly given Dr ████████ evidence that it is difficult to assess whether somebody is breathing or not by looking for movement in the chest/abdomen from a distance.
1. The observation of an individual’s chest/abdomen through a cell door hatch may be an unreliable method of checking whether they are breathing , in circumstances in which they are not otherwise moving or responding to prison staff, and therefore gives rise to the risk of future deaths.
” Open source report
4 Jun 2021 Angela Rosemary BEST · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 2 Lack of assigned responsibility and authority to investigate relationship status View source Reliance on self-reporting to monitor relationship status despite known untruthfulness View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Angela Rosemary BEST · 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 Best was murdered by her former partner, who was convicted of her murder. The principal concern was that monitoring of his relationship status relied almost entirely on his self-reporting, despite his known history of dishonesty and the assessed increase in risk when he was in a relationship. He was in a relationship with Angela Best for approximately 20 years without detection and killed her when she ended it.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Lack of assigned responsibility and authority to investigate relationship status
Wider context from the report “The successive mental health trusts who acted as lead agency had the responsibility for monitoring the man’s relationship status and his mental health (which never deteriorated). However, no person or organisation had the role, responsibility or power to investigate his relationship status . The monitoring of whether he was in a relationship was almost entirely based upon his self reporting.
In fact, when this condition of discharge was imposed in 1997, the man was already known to have been untruthful about his relationship status. He continued to be untruthful about it.
In such a situation, evidence may come to light via other agencies, for example if complaints of domestic violence are made to the police, but it did not in this instance. Thus, a matter important enough to be made a condition of discharge, depended upon the truthfulness and openness of an untruthful, two time killer who had a vested interest in withholding the relevant information. Unreliability was built in to the system.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Reliance on self-reporting to monitor relationship status despite known untruthfulness
Wider context from the report “The successive mental health trusts who acted as lead agency had the responsibility for monitoring the man’s relationship status and his mental health (which never deteriorated). However, no person or organisation had the role, responsibility or power to investigate his relationship status. The monitoring of whether he was in a relationship was almost entirely based upon his self reporting.
In fact, when this condition of discharge was imposed in 1997, the man was already known to have been untruthful about his relationship status . He continued to be untruthful about it.
In such a situation, evidence may come to light via other agencies, for example if complaints of domestic violence are made to the police, but it did not in this instance. Thus, a matter important enough to be made a condition of discharge, depended upon the truthfulness and openness of an untruthful, two time killer who had a vested interest in withholding the relevant information . Unreliability was built in to the system.
” 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 Revise guidance for discharged patients to promote professional curiosity, challenge, wider information-seeking and reduced reliance on self-reporting.
Verbatim wording from the response “Review of Conditions of Discharge and Associated MHCS Guidance: Mr Johnson had a condition ‘to notify his/her supervising team (his Responsible Clinician and Social Supervisor) of any close relationship he/she was having or was developing’. Conditional discharge reports routinely provided updates on Mr Johnson’s relationship status, based on his own self reporting. Officials will review the MHCS condition applied to relationships, to explore whether additional or amended conditions may assist. This will be subject to informal consultation with stakeholders (such as the Forensic Faculty of the Royal College of Psychiatrists). MHCS guidance on discharged patients will be revised to promote and support the sort of professional curiosity and challenge that is acknowledged practice in fields of probation supervision, social work, domestic violence, safeguarding and adult social care.” Source location 2021-0194-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 conditional discharge report templates to facilitate information-sharing and set expectations that self-reporting is insufficient.
Verbatim wording from the response “We will encourage a” Source location 2021-0194-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 Review relationship-related conditions of discharge, with stakeholder consultation, to assess whether additional or amended conditions are needed.
Verbatim wording from the response “Review of Conditions of Discharge and Associated MHCS Guidance: Mr Johnson had a condition ‘to notify his/her supervising team (his Responsible Clinician and Social Supervisor) of any close relationship he/she was having or was developing’. Conditional discharge reports routinely provided updates on Mr Johnson’s relationship status, based on his own self reporting. Officials will review the MHCS condition applied to relationships, to explore whether additional or amended conditions may assist. This will be subject to informal consultation with stakeholders (such as the Forensic Faculty of the Royal College of Psychiatrists). MHCS guidance on discharged patients will be revised to promote and support the sort of professional curiosity and challenge that is acknowledged practice in fields of probation supervision, social work, domestic violence, safeguarding and adult social care.” Source location 2021-0194-Response-from-MoJ_Published
Open published response
2 Jun 2021 Mark Samuel CULVERHOUSE · Prevention of Future Deaths report Milton Keynes
View report summary
Concerns raised 1 Failure to calculate prisoners’ release dates before recall decisions View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Mark Samuel CULVERHOUSE · 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 Samuel Culverhouse died in hospital on 24 April 2019 after being found with a ligature around his neck in a segregation cell at HMP Woodhill. The inquest jury concluded that he died from suicide, and that his unlawful detention and the decision to place him in segregation contributed to his death. The report identified concerns about the failure to calculate his release date before his recall and detention.
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 calculate prisoners’ release dates before recall decisions
Wider context from the report “During the course of the inquest into the death of Mark Culverhouse it became apparent, and indeed was accepted that his detention at HMP Woodhill from the 18th of April 2019 until the 23rd of April 2019 was unlawful. He had been recalled under the terms of his license having been released from Peterborough prison on the 12th of April 2019. The calculation of his release date was not conducted by the offender management unit at the prison until the 23rd of April 2019, after the extended Easter bank holiday. I was told that there was no process in place whereby a prisoner’s release is calculated until such time as they come back into custody . The prison and probation ombudsman brought this matter to the attention of the prison service recommending that the release date calculation should take place within one working day of the prisoner arriving in prison. I cannot see how that can be acceptable particularly where, in Mr Culverhouse’s case, it would have made no difference because of the bank holiday. I consider that there was a clear link between his unlawful detention and his eventual death on the 24th of April 2019 and, in order to prevent similar deaths in the future, I believe an urgent review is required and the system changed to ensure that the calculation of the release date is made prior to the decision to recall being taken. This will avoid the possibility of anyone being unlawfully imprisoned in this country under similar circumstances.
” Open source report
Concerns raised 3 Failure to maintain adequate hygiene and deep cleaning in non-clinical Health Care Centre areas View source Failure to conduct required VTE risk reviews for anti-coagulation decisions View source Failure of the clinical system to detect missed VTE risk 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
Alvin Roy Black · 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
Alvin Roy Black, a serving prisoner, died after developing breathing difficulties and chest pains two days after returning from hospital spinal surgery. He suffered a fatal pulmonary embolism and cardiac arrest despite CPR. Concerns included poor hygiene in the prison Health Care Centre and a missed opportunity to review whether anti-coagulation therapy should have been provided after surgery.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain adequate hygiene and deep cleaning in non-clinical Health Care Centre areas
Wider context from the report “(1) Extensive evidence was heard concerning the poor state of cleanliness of the Health Care Centre at the Prison . Evidence confirmed that the ground floor of the Health Care Centre was not part of the clinical areas for which the Northamptonshire NHS Foundation Trust, the providers of health care at the Prison, were responsible: this area remained the responsibility of the Ministry of Justice. Whilst Health Care patients would regularly be located there, designated ‘vulnerable prisoners’ were also routinely resident in this location and, in respect of this cohort, there would be both a high turnover and sometimes challenging hygiene issues accompanying them. The evidence confirmed that the levels of hygiene in the common ways, kitchens, sinks, showers and the cells was poor and that this was of concern to prisoner patients and medical staff alike. Evidence also confirmed that no ‘deep cleans’ took place in these areas save where blood, vomit or a ‘dirty protest’ was specifically involved . I am concerned that such poor levels of hygiene give rise to the risk of prisoners returning from surgery, with perhaps compromised immune systems, facing a significant risk of infection, itself giving rise to a risk of future death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct required VTE risk reviews for anti-coagulation decisions
Wider context from the report “(2) Evidence disclosed, and was conceded by the Trust, that there had been a missed opportunity for consideration of whether or not anti-coagulation therapy should have been provided to Mr Black following the decision that he remain in Addenbrookes Hospital over-night on the 13th November following his surgery. Although she had been prompted by a pharmacist to review the VTE risk once the decision had been made that it was “unsafe” to discharge Mr Black on the afternoon of the 13th, the Senior House Officer involved failed to conduct the review as required by both NICE and Trust policy . Although this was on the face of it an individual failure by the SHO, I am concerned that (a) the system in place at the time did not pick up on this error; (b) that the SHO’s evidence indicated that the course she took was, in her experience, standard practice ; and (c) in different clinical circumstances, the failure to ensure that the appropriate review took place gives rise to the risk of future (preventable) death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure of the clinical system to detect missed VTE risk reviews
Wider context from the report “(2) Evidence disclosed, and was conceded by the Trust, that there had been a missed opportunity for consideration of whether or not anti-coagulation therapy should have been provided to Mr Black following the decision that he remain in Addenbrookes Hospital over-night on the 13th November following his surgery. Although she had been prompted by a pharmacist to review the VTE risk once the decision had been made that it was “unsafe” to discharge Mr Black on the afternoon of the 13th, the Senior House Officer involved failed to conduct the review as required by both NICE and Trust policy. Although this was on the face of it an individual failure by the SHO, I am concerned that (a) the system in place at the time did not pick up on this error ; (b) that the SHO’s evidence indicated that the course she took was, in her experience, standard practice; and (c) in different clinical circumstances, the failure to ensure that the appropriate review took place gives rise to the risk of future (preventable) death.
” Open source report
23 Apr 2021 Guy Clifton Paget · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 2 Failure to communicate the urgent need for ambulance-exit authorisation and have the authorisation prepared View source Lack of an effective and tested system for admitting emergency ambulance vehicles and facilitating their exit with prisoners View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Guy Clifton Paget · 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
Guy Clifton Paget, a prisoner at HMP Leeds with terminal oesophageal cancer, was found confused in his cell on 16 March 2021 and died at 15:06 that day in an ambulance at the prison gate. The ambulance could not leave because of incorrect paperwork and a malfunctioning vehicle gate. The concerns related to the need for effective, urgent, and tested systems to enable emergency ambulances to enter and leave prisons with prisoners requiring hospital treatment.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate the urgent need for ambulance-exit authorisation and have the authorisation prepared
Wider context from the report “1. The prison should have effective systems to facilitate the exit of an emergency ambulance from the prison.
2. In this case a decision was made shortly after 13:00 that Mr Paget needed to be taken to hospital. It should have been made clear to the prison managers that the necessary authorisation to exit needed to be prepared as a matter of urgency. At approximately 15:00 hours, however, this was not in place.
3. It is foreseeable that prisons nationally will need to admit paramedics and ambulance vehicles to attend to prisoners at times of emergency – and may then need to leave with the prisoner in the ambulance. An efficient and tested system to manage this process is essential, in order that serving prisoners are provided with an equivalent level of care to that which they could expect in 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 Lack of an effective and tested system for admitting emergency ambulance vehicles and facilitating their exit with prisoners
Wider context from the report “1. The prison should have effective systems to facilitate the exit of an emergency ambulance from the prison.
2. In this case a decision was made shortly after 13:00 that Mr Paget needed to be taken to hospital. It should have been made clear to the prison managers that the necessary authorisation to exit needed to be prepared as a matter of urgency. At approximately 15:00 hours, however, this was not in place.
3. It is foreseeable that prisons nationally will need to admit paramedics and ambulance vehicles to attend to prisoners at times of emergency – and may then need to leave with the prisoner in the ambulance. An efficient and tested system to manage this process is essential , in order that serving prisoners are provided with an equivalent level of care to that which they could expect in the community.
” Open source report
22 Apr 2021 Kelly Frances HEWITT · Prevention of Future Deaths report Milton Keynes
View report summary
Concerns raised 1 Lack of mental health support for prison staff View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Kelly Frances HEWITT · 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
Kelly Frances HEWITT, a prison officer, was found hanging at her home on 18 December 2018 and was confirmed dead by paramedics. She had been suffering from depression, which was recognised by work colleagues and prison managers. Concerns were expressed about the lack of mental health support available to prison officers, and the report states that this provision should be reviewed.
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 mental health support for prison staff
Wider context from the report “Concerns were expressed throughout the inquest as to the lack of mental health support available to prison officers .
” Open source report
Concerns raised 1 Inadequate control of access to novel psychoactive substances within the prison View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Luke Morris Jones · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Luke Morris Jones, a prisoner at HMP Berwyn, was found unresponsive after smoking a novel psychoactive substance and died on 31 March 2018 despite medical intervention. The report identified concerns about the accessibility and continuing availability of novel psychoactive substances in the prison and the associated risks to health.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Inadequate control of access to novel psychoactive substances within the prison
Wider context from the report “The report of the Prisons and Probation Ombudsman highlighted that there were concerns regarding the accessibility of drugs within HMP Berwyn and notwithstanding that certain measures had been taken at HMP Berwyn (namely in relation to the installation of a Rapiscan to test some of the incoming mail), evidence at the inquest confirmed that the continuing availability and use of novel psychoactive substances .
By way of example, the evidence of the prison GP indicated that at least one instance of a prisoner being intoxicated was reported to him each day which he worked and as a result I consider it highly probable that the combination of the accessibility of NPS and the significant risks which they pose to health will be the cause of future deaths at the prison.
” Open source report
20 Nov 2019 Mr Gary Leyland · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 8 Failure to redirect concerns or contact the person's GP View source Failure to update handover information about expected welfare checks View source Failure to maintain complete and reliable welfare-check records View source Lack of a staff policy for responding to self-harm or suicide issues View source Lack of a policy directing staff where to raise clearly present non-imminent concerns View source Failure to contact relevant medical or mental health services about identified concerns View source Lack of training and information for security staff on self-harm and suicide risk View source Failure to conduct updated risk assessments View source See 5 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
Mr Gary Leyland · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mr Gary Leyland was found deceased in his supported accommodation on 13 November 2019 after taking excessive prescribed medication, with the inquest conclusion recording suicide and morphine toxicity. Concerns included failures to contact medical or mental health services after suicidal thoughts were disclosed, poor documentation and handover information, the use of security staff for welfare checks without clear evidence of training, and the absence of an updated risk assessment.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to redirect concerns or contact the person's GP
Wider context from the report “5. The Court heard evidence that Oldham Council who commissioned the supported accommodation through Jigsaw Homes Group. The Court heard evidence part of the contract provision for the service includes the fact that Threshold ( the brand of Jigsaw Homes which provided the Spring Street accommodation ) must comply with certain policies which included risk assessment and risk management and Safeguarding Adults. However no evidence was provided to the Court as to any self-harm or suicide policy available to staff relating to how they should deal with such issues which may arise. In this case Spring Street clearly took responsibility by virtue of their plan (welfare checks, update risk assessment etc) for Mr Leylands welfare once they were put on notice of the Probation Service concerns. No attempt was made to re-direct the Probation Service to another agency ie Mr Leylands GP nor was any attempt made by Spring Street to contact Mr Leylands GP.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to update handover information about expected welfare checks
Wider context from the report “2. Only the handover sheets for the 7th and 8th November were updated to advise staff to “keep an eye” on Mr Leyland. NO updates were on the handover sheets for the 9-12th November despite the evidence being welfare checks would still have been expected on these dates. It is therefore unclear how security staff working the 10th and 11th November (weekend) would have been able to expect to check on Mr Leyland.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain complete and reliable welfare-check records
Wider context from the report “1. Documentation and Recording of Information - during the course of the Inquest the Court was provided with and taken to various documents and records relating to Mr Leyland. The Court found the recording and documentation to be of a poor quality and standard. The chronology document was not complete, information as to when Mr Leyland had been seen was missing. The observational log was completed in some instances with the use of an X as opposed to the staff members initials so it was not clear if he had been seen and if so by whom.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 staff policy for responding to self-harm or suicide issues
Wider context from the report “5. The Court heard evidence that Oldham Council who commissioned the supported accommodation through Jigsaw Homes Group. The Court heard evidence part of the contract provision for the service includes the fact that Threshold ( the brand of Jigsaw Homes which provided the Spring Street accommodation ) must comply with certain policies which included risk assessment and risk management and Safeguarding Adults. However no evidence was provided to the Court as to any self-harm or suicide policy available to staff relating to how they should deal with such issues which may arise. In this case Spring Street clearly took responsibility by virtue of their plan (welfare checks, update risk assessment etc) for Mr Leylands welfare once they were put on notice of the Probation Service concerns. No attempt was made to re-direct the Probation Service to another agency ie Mr Leylands GP nor was any attempt made by Spring Street to contact Mr Leylands GP.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 policy directing staff where to raise clearly present non-imminent concerns
Wider context from the report “1. Due to the fact Mr Leyland was residing in supported accommodation the Probation Officer reported her concerns to the Spring Street. However no attempt was made to contact any medical practitioner ie GP or mental health services. It was unclear at the conclusion of the Inquest whether there is a policy within the Probation for staff vindicating to whom concerns should be raised for example if Mr Leyland had been residing in his own home and where the risk is not believed to be imminent although clearly present.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 contact relevant medical or mental health services about identified concerns
Wider context from the report “1. Due to the fact Mr Leyland was residing in supported accommodation the Probation Officer reported her concerns to the Spring Street. However no attempt was made to contact any medical practitioner ie GP or mental health services. It was unclear at the conclusion of the Inquest whether there is a policy within the Probation for staff vindicating to whom concerns should be raised for example if Mr Leyland had been residing in his own home and where the risk is not believed to be imminent although clearly present.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Lack of training and information for security staff on self-harm and suicide risk
Wider context from the report “3. The fact that the expectation was security staff would be expected to conduct welfare checks at a weekend was heard for the first time in evidence. There was no evidence as to how they are trained, what information is provided to them about self -harm and the risk of suicide. This practice was of grave concern to the Court.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 updated risk assessments
Wider context from the report “4. The Court heard there was no updated risk assessment conducted as was envisaged following the email from the Probation Service.
” Open source report
5 Oct 2019 Master Alex Malcolm · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 3 Inadequate arrangements for responding to domestic violence View source Difficulties in recruitment and retention of probation officers View source Insufficient availability of Approved Premises places 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
Master Alex Malcolm · 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
Master Alex Malcolm, aged 5, died on 22 November 2016 from a head injury and was found to have been unlawfully killed; a perpetrator was convicted of murder. The jury identified concerns including the perpetrator’s misclassification, failures to share information and safeguard the deceased’s mother, inadequate probation supervision, failure to secure approved premises, and failures to respond to licence breaches. Further concerns included shortages of approved premises, domestic-violence safeguarding arrangements, and recruitment and retention difficulties among probation officers.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Inadequate arrangements for responding to domestic violence
Wider context from the report “2. The Chair of the Serious Case Review subgroup of Lambeth Safeguarding Children Board said that strengthening any arrangements around domestic violence , including putting MARACs on a statutory basis had the potential to save lives. The senior Coroner raised this issue in a Prevention of Future Deaths Report to the Secretary of State for Health earlier this year, triggered by the chair of a domestic homicide review into the death of Donna Williamson. Her evidence was clear that there were arguments for MARAC and other bodies to be put on a statutory footing and for the system to be reviewed . The response from the ministry did not specifically address the issue.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Difficulties in recruitment and retention of probation officers
Wider context from the report “3. A senior NPS divisional head said that there were still difficulties in recruitment and retention of probation officers , one factor in which was low pay. It is understood the matter is under review but details of what steps have since been taken and their adequacy were not heard by the coroner.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 availability of Approved Premises places
Wider context from the report “1. A senior NPS divisional head said that providing more Approved Premises places would potentially save lives . It is understood the matter is under review but details of what steps have since been taken were not heard by the coroner.
” Open source report
2 Oct 2019 Philip Vernon Owen · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 6 Lack of a significant licence period for Probation Service supervision View source Failure to ensure safe release from custody for high-risk offenders eligible for immediate release after very short custodial sentences View source Failure to provide the court with sufficient information about the level of risk View source Failure to effectively communicate release risks to those involved in sentencing View source Lack of guidance for sentencing participants on minimising risks to the public View source Lack of clear expectations or guidance for those assisting a sentencing court 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
Philip Vernon Owen · 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
Philip Vernon Owen was found dead in his flat on 30 October 2016 after being killed by a stab wound to the neck. The report describes failures in mental health risk assessment, discharge planning and communication after the perpetrator’s release from custody, and concerns about how risks associated with short custodial sentences were communicated to sentencing courts and managed by relevant 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 a significant licence period for Probation Service supervision
Wider context from the report “The Inquest heard evidence from the Prison and Probation Service that, as was demonstrated in this case, there are significant challenges that are difficult to mitigate to ensure a safe release from custody where a very short custodial sentence is imposed which means an individual who is a high risk offender is eligible for immediate release. This is compounded where as in this case there is no significant licence period that the Probation Service can supervise ;
There was a lack of clarity as to how effectively these risks had been communicated to those involved in sentencing and what if any guidance existed support them in taking steps to minimise the risks to the public;
It was unclear how much information was shared with the court regarding the level of risk by the Prosecution or the Probation Service and what expectations were or guidance to those assisting a sentencing court in the discharge of their duty.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 safe release from custody for high-risk offenders eligible for immediate release after very short custodial sentences
Wider context from the report “The Inquest heard evidence from the Prison and Probation Service that, as was demonstrated in this case, there are significant challenges that are difficult to mitigate to ensure a safe release from custody where a very short custodial sentence is imposed which means an individual who is a high risk offender is eligible for immediate release . This is compounded where as in this case there is no significant licence period that the Probation Service can supervise;
There was a lack of clarity as to how effectively these risks had been communicated to those involved in sentencing and what if any guidance existed support them in taking steps to minimise the risks to the public;
It was unclear how much information was shared with the court regarding the level of risk by the Prosecution or the Probation Service and what expectations were or guidance to those assisting a sentencing court in the discharge of their duty.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 the court with sufficient information about the level of risk
Wider context from the report “The Inquest heard evidence from the Prison and Probation Service that, as was demonstrated in this case, there are significant challenges that are difficult to mitigate to ensure a safe release from custody where a very short custodial sentence is imposed which means an individual who is a high risk offender is eligible for immediate release. This is compounded where as in this case there is no significant licence period that the Probation Service can supervise;
There was a lack of clarity as to how effectively these risks had been communicated to those involved in sentencing and what if any guidance existed support them in taking steps to minimise the risks to the public;
It was unclear how much information was shared with the court regarding the level of risk by the Prosecution or the Probation Service and what expectations were or guidance to those assisting a sentencing court in the discharge of their duty.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 effectively communicate release risks to those involved in sentencing
Wider context from the report “The Inquest heard evidence from the Prison and Probation Service that, as was demonstrated in this case, there are significant challenges that are difficult to mitigate to ensure a safe release from custody where a very short custodial sentence is imposed which means an individual who is a high risk offender is eligible for immediate release. This is compounded where as in this case there is no significant licence period that the Probation Service can supervise;
There was a lack of clarity as to how effectively these risks had been communicated to those involved in sentencing and what if any guidance existed support them in taking steps to minimise the risks to the public;
It was unclear how much information was shared with the court regarding the level of risk by the Prosecution or the Probation Service and what expectations were or guidance to those assisting a sentencing court in the discharge of their duty.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 for sentencing participants on minimising risks to the public
Wider context from the report “The Inquest heard evidence from the Prison and Probation Service that, as was demonstrated in this case, there are significant challenges that are difficult to mitigate to ensure a safe release from custody where a very short custodial sentence is imposed which means an individual who is a high risk offender is eligible for immediate release. This is compounded where as in this case there is no significant licence period that the Probation Service can supervise;
There was a lack of clarity as to how effectively these risks had been communicated to those involved in sentencing and what if any guidance existed support them in taking steps to minimise the risks to the public ;
It was unclear how much information was shared with the court regarding the level of risk by the Prosecution or the Probation Service and what expectations were or guidance to those assisting a sentencing court in the discharge of their duty.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Lack of clear expectations or guidance for those assisting a sentencing court
Wider context from the report “The Inquest heard evidence from the Prison and Probation Service that, as was demonstrated in this case, there are significant challenges that are difficult to mitigate to ensure a safe release from custody where a very short custodial sentence is imposed which means an individual who is a high risk offender is eligible for immediate release. This is compounded where as in this case there is no significant licence period that the Probation Service can supervise;
There was a lack of clarity as to how effectively these risks had been communicated to those involved in sentencing and what if any guidance existed support them in taking steps to minimise the risks to the public;
It was unclear how much information was shared with the court regarding the level of risk by the Prosecution or the Probation Service and what expectations were or guidance to those assisting a sentencing court in the discharge of their duty .
” Open source report
29 Aug 2019 Michael Hoolickin · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 15 Insufficient capacity to cross-reference offender intelligence across offenders and agencies View source Failure to require ACOs to access offender records View source Lack of formal information-sharing procedures for integrated teams View source Poor or absent records by SPOs and ACOs View source Failure to undertake multi-agency reviews after high-risk offenders under multi-agency management kill someone View source Lack of training on accessing drug test results View source Failure to update OASYS risk assessments View source Insufficient planning and preparation for service amalgamation View source N-Delius failing to provide timely access to current offender information View source Inadequate agenda, minutes, attendance records and meeting records for IOM cohort meetings View source Failure to accurately share information about offenders between police forces View source Lack of induction training and office procedures on local drug-testing practices View source Lack of clarity and specific instructions on ACO warnings View source Lack of clear arrangements for initiating police curfew checks View source Failure to record licence conditions on the Police National Computer View source See 12 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Michael Hoolickin · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Michael Hoolickin was attacked and stabbed in an unprovoked assault on 14 October 2016 and died at Manchester Royal Infirmary on 17 October 2016. The report identifies organisational and management failures in supervising the perpetrator, including failures concerning drug testing, information sharing and provision of relevant information, which resulted in a missed opportunity to initiate recall to prison. The Inquest found that this probably contributed to Michael Hoolickin’s death, although it was not causative of the attack.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Insufficient capacity to cross-reference offender intelligence across offenders and agencies
Wider context from the report “During the course of the Inquest questions were raised around the ability of the NPS to cross reference intelligence received in respect of different offenders . In addition whether there was capacity to cross reference intelligence held by other agencies such as the Youth Offending Team .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to require ACOs to access offender records
Wider context from the report “There is no expectation for an ACO to access an offenders records on the case management system in order to inform themselves or to consider whether there is any further relevant information.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Lack of formal information-sharing procedures for integrated teams
Wider context from the report “The evidence before the Court was there are no Standard Operating procedures or formal processes in place for the sharing of information when teams are integrated .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Poor or absent records by SPOs and ACOs
Wider context from the report “The Court had serious concerns as to the poor records or complete lack of records particularly by SPOs and the ACOs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake multi-agency reviews after high-risk offenders under multi-agency management kill someone
Wider context from the report “The failure to undertake a multi-agency review in cases where a high risk offender subject to multi-agency management has gone on to take someone’s life means both organisational and individual failings are not identified and there is a missed opportunity to learn lessons in order to prevent future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Lack of training on accessing drug test results
Wider context from the report “The Court found there was an ineffective national system in use in 2016 (N Delius) for which there had been no training on how to access Drug test results . As a result individual offices had implemented their own systems for storing drug test results. However there is no induction training, information available to staff in individual offices by way of office procedures which informs staff of local practices.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to update OASYS risk assessments
Wider context from the report “At no stage after March 2016 was the offenders OASYS risk assessment updated . Moreover the lack of formal supervision meant this was not addressed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Insufficient planning and preparation for service amalgamation
Wider context from the report “The Court has concerns as to the planning and preparation required for the amalgamation of any new service in order to alleviate the evidenced problems which occurred as a direct result of the previous Transforming Rehabilitation programme.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation N-Delius failing to provide timely access to current offender information
Wider context from the report “Numerous witnesses gave evidence as to the difficulties in accessing this system , its design and the time it takes to access the different parts which hold pertinent information about an offender , describing this as prohibitive. For example for Offender managers trying to read through the file to obtain current information there is nowhere which would easily show the most up to date curfew or the most up to date position as to how often drug testing is being conducted .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 agenda, minutes, attendance records and meeting records for IOM cohort meetings
Wider context from the report “The evidence before the Court was that in respect of the multi-agency IOM meetings there was no formal agenda, no formal minutes, no accurate record kept of these meetings by either GMP or the NPS and no way of ascertaining who had attended these meetings .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 accurately share information about offenders between police forces
Wider context from the report “There was a complete breakdown of communication and information sharing between GMP and Lancashire Constabulary which lead to only information about one of the two offenders being passed on . More importantly there was confusion between the forces as to which offender was being discussed .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 induction training and office procedures on local drug-testing practices
Wider context from the report “The Court found there was an ineffective national system in use in 2016 (N Delius) for which there had been no training on how to access Drug test results. As a result individual offices had implemented their own systems for storing drug test results. However there is no induction training, information available to staff in individual offices by way of office procedures which informs staff of local practices .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 clarity and specific instructions on ACO warnings
Wider context from the report “The Court found there is a lack of clarity and specific instructions to the NPS on this point.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Lack of clear arrangements for initiating police curfew checks
Wider context from the report “The Court was satisfied from the evidence that there is no clear understanding as to the initiation of curfew checks . It was clear to the Court there was confusion as to whether an offender on a curfew will automatically be subject to curfew checks carried out by the Police or whether such checks will only be conducted following a specific request by the NPS .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 licence conditions on the Police National Computer
Wider context from the report “The Court heard that an offenders’ licence conditions are not held on the Police National Computer database . Hence if an offender is arrested by a different force they are unlikely to know whether the offender may be in breach of their licence.
” Open source report
16 Aug 2019 Martin Leslie Haines · Prevention of Future Deaths report East Sussex
View report summary
Concerns raised 7 Failure to carry out diagnostic testing and monitoring for diabetes View source Fragmentation of responsibility for prison healthcare across multiple organisations View source Standard of care falling below community level View source Failure to confirm cardiovascular disease View source Availability of means to brew or distil alcohol View source Lack of protocols or agreements for responding to an unresponsive body View source Insufficient communication and information sharing between prison healthcare organisations View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Martin Leslie Haines · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Martin Leslie Haines was detained at Lewes Prison and was found dead in his cell on 18 March 2018. He had Type II Diabetes and warning signs of cerebrovascular disease, but the appropriate diagnostic tests were not carried out; alcohol, Venlafaxine and Amitriptyline were later found in his system and considered by the pathologist to have contributed to his death. The principal concerns included inadequate diabetes and cardiovascular monitoring, healthcare falling below community standards, the ability to brew or distil alcohol in prison, a lack of protocols for responding to an unresponsive body, and insufficient communication between healthcare providers and the prison 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 carry out diagnostic testing and monitoring for diabetes
Wider context from the report “(2) The failure to carry out diagnostic testing and monitoring for his diabetes and to confirm his considerable cardiovascular disease.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Fragmentation of responsibility for prison healthcare across multiple organisations
Wider context from the report “(5) In my opinion, the underlying problems were due to the fact that responsibility for healthcare in the prison was split between the prison service, Sussex Partnership Foundation Trust (which is a mental health provider but was also contracted to run all healthcare, both physical and mental within the prison), Medco Ltd who provided the GPs and Forward Trust who were contracted to treat alcohol and substance misuse in the prison . There was insufficient communication between these bodies and they had separate IT databases.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Standard of care falling below community level
Wider context from the report “(3) The standard of care appears to have fallen well below that which he could have received in 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 Failure to confirm cardiovascular disease
Wider context from the report “(2) The failure to carry out diagnostic testing and monitoring for his diabetes and to confirm his considerable cardiovascular disease .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Availability of means to brew or distil alcohol
Wider context from the report “(1) The fact that the deceased was able to brew or distil his own alcohol .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 protocols or agreements for responding to an unresponsive body
Wider context from the report “(4) There were no protocols or agreements between healthcare staff and the prison service as to how best to respond to an unresponsive body .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Insufficient communication and information sharing between prison healthcare organisations
Wider context from the report “(5) In my opinion, the underlying problems were due to the fact that responsibility for healthcare in the prison was split between the prison service, Sussex Partnership Foundation Trust (which is a mental health provider but was also contracted to run all healthcare, both physical and mental within the prison), Medco Ltd who provided the GPs and Forward Trust who were contracted to treat alcohol and substance misuse in the prison. There was insufficient communication between these bodies and they had separate IT databases .
” Open source report
16 Aug 2019 Justin Peter Gallagher · Prevention of Future Deaths report East Sussex
View report summary
Concerns raised 9 Failure to identify and diagnose cancer View source Failure to obtain previous medical history View source Lack of a system for arranging external hospital visits View source Lack of a single clinician responsible for patient care View source Failure to draft proper care plans View source Lack of resources for attending external hospital appointments View source Fragmented responsibility for prison healthcare View source Failure of healthcare organisations to use integrated database systems View source Failure to involve family in obtaining important patient information View source See 6 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
Justin Peter Gallagher · 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
Justin Peter Gallagher was received at HMP Lewes on 20 March 2016 and was later found collapsed in his segregation-block cell on 24 May 2016. He was taken to hospital, where he died on 17 June 2016; the post-mortem recorded hypoxic brain injury, cardiac arrest and laryngeal carcinoma with upper airway obstruction among the causes. Concerns included the absence of his previous medical history, a proper care plan and a single clinician responsible for his care, cancelled hospital appointments, missed opportunities to diagnose his cancer, lack of family involvement, and separate healthcare organisations using unconnected database systems.
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 and diagnose cancer
Wider context from the report “(3) The deceased died of cancer but this had never been diagnosed and opportunities to have discovered his condition were 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 obtain previous medical history
Wider context from the report “(1) The prison never obtained his previous medical history. No proper care plan was drafted for him and there was no single clinician responsible for his care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 arranging external hospital visits
Wider context from the report “(2) A number of external hospital appointments were cancelled at short notice because of lack of resources (no available escorts etc.) and there was no system available for arranging such visits .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 clinician responsible for patient care
Wider context from the report “(1) The prison never obtained his previous medical history. No proper care plan was drafted for him and there was no single clinician responsible for his care .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 draft proper care plans
Wider context from the report “(1) The prison never obtained his previous medical history. No proper care plan was drafted for him and there was no single clinician responsible for his care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 resources for attending external hospital appointments
Wider context from the report “(2) A number of external hospital appointments were cancelled at short notice because of lack of resources (no available escorts etc.) and there was no system available for arranging such visits.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Fragmented responsibility for prison healthcare
Wider context from the report “(5) The underlying problem was that healthcare in the prison was the responsibility of three different organisations , namely the prison service, the local mental health NHS Trust (who were given the responsibility of dealing with all physical health matters and running the healthcare centre), and a separate organisation who supplied GPs. These three organisations had entirely separate database systems.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure of healthcare organisations to use integrated database systems
Wider context from the report “(5) The underlying problem was that healthcare in the prison was the responsibility of three different organisations, namely the prison service, the local mental health NHS Trust (who were given the responsibility of dealing with all physical health matters and running the healthcare centre), and a separate organisation who supplied GPs. These three organisations had entirely separate database systems.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 involve family in obtaining important patient information
Wider context from the report “(4) There was no involvement of the family and so a source of important information was missed .
” Open source report
Concerns raised 11 Failure to carry and use personal protective equipment View source Failure of probation staff to engage in full updating training View source Failure to challenge or support change in domestic abuse risk during probation supervision View source Failure to allocate an appropriately protective MAPPA level for offenders with significant domestic abuse histories who have not been fully tested before release View source Failure to detail licence conditions during MAPPA Level 1 management View source Failure to obtain information during initial attendances on reported domestic abuse incidents View source Insufficient probation staffing capacity for complex and demanding casework View source Failure to evidence implementation of recommended safety changes View source Lack of mandated joined-up inter-agency communication at offender release or when new personal relationships develop View source Deficiencies in initial grading of calls to identify initial responses View source Failure to maintain mandatory inter-agency information sharing for MAPPA Level 1 management 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
Cherylee Yvette Shennan · 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
Cherylee Yvette Shennan, a 40-year-old woman, was murdered on 17 March 2014 by a former offender who had subjected her to domestic abuse, including serious violence. The report raised concerns about inadequate inter-agency communication and management of the perpetrator, including the absence of a mandatory process for sharing information when an offender with a known history of domestic abuse was managed at MAPPA Level 1.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to carry and use personal protective equipment
Wider context from the report “Following the death of Cherylee, her death, and actions taken in the months leading up to it were the subject of two detailed reviews. Following the Domestic Homicide Review a number of recommendations were made by the author of the Individual Management Report, Mr Gary Fishwick including concerns regarding initial grading of calls to identify initial responses, the obtaining of information as part of initial attendances on reported domestic abuse incidents and the carrying and use of personal protective equipment . Whilst the recommendations were made, Mr Fishwick could give no evidence at the inquest into the death of Cherylee to indicate whether those recommendations had in fact been actioned or not, and accordingly whether anything had changed following the death of Cherylee and the learning exercise that were subsequently undertaken.
In particular reference was made to, but unsupported by documentation, or any other form of evidence:
• Policies reflecting recommended changes;
• Information sharing agreements between agencies;
• MARAC emergency policy or notes;
• DASH Training or policy regarding obtaining GP details; and
• Audits of Grade 2 ‘Ethical fails’ and reasons for such fails.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure of probation staff to engage in full updating training
Wider context from the report “3) Finally it was also accepted by senior probation witnesses that although staff had access to updated training information, due to pressures of their workloads they lacked the time to engage in full updating training .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to challenge or support change in domestic abuse risk during probation supervision
Wider context from the report “2) Evidence was further heard regarding the Report of the Chief Inspector of Probation 2019 and in particular the finding that "Many individuals were drifting through their supervision period without being challenged or supported to change their prediction for domestic abuse " and that "The number of probation professionals is now at a critical level. There is a national shortage of professional probation staff and especially those mainly responsible for more complex and demanding casework". It was agreed by those senior probation witnesses that staffing and workloads had been an issue in this matter, as found by the jury, and furthermore continued to be so.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 allocate an appropriately protective MAPPA level for offenders with significant domestic abuse histories who have not been fully tested before release
Wider context from the report “1) During the course of the inquest statistics regarding the nature of domestic abuse were repeatedly reviewed and accepted by senior member of both probation and police services. In particular domestic abuse features in about half of all cases managed by probation staff and that in the year to the end of 2018 of the 659 homicides 1 in 10 were committed by a partner. Evidence was heard of the MAPPA process, for the managing of risk of offenders to be released on licence, and for the interagency sharing of information regarding those offenders. During the course of the evidence it was made clear that the perpetrator in this instance was a very dangerous individual, who was described as controlling and manipulative, and who, it was accepted by the witnesses involved in his management, was likely to have controlled his meetings by his nature, and by partial disclosures of information. The underlying issue that arose from both the various reviews that took place after the death of Cherylee Shennan, and from the inquest was that there was no substantial interagency communication following the perpetrator's release on licence, which would, the jury found, have allowed the sharing of his licence conditions and action plans to be put in place by local police forces. The jury concluded that such a failing possibly contributed to the death on the 17th March 2014. At the inquest no evidence was heard regarding any changes to MAPPA or the guidance given. Whilst the evidence heard was that the MAPPA level allocated to an individual is fluid, and would be based upon their risks and presentation at that time, my concern centres on the issue that an offender who has served a significant sentence and accordingly has never been fully tested before release on licence, and who has a significant history of domestic abuse and violence, will still be released on MAPPA level 1 . On the evidence that was heard there remains no mandated process for joined up inter-agency working or communication at the point of their release, or when they develop new personal relationships.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 detail licence conditions during MAPPA Level 1 management
Wider context from the report “The perpetrator was managed on release at MAPPA Level 1. Following his release there were no local MAPPA 1 meetings, no inter-agency meetings and no significant inter-agency communications regarding the perpetrator, no detailing of his licence conditions , and no information regarding either his nature or the trigger factors for his offending. Evidence was heard regarding the findings of two separate reviews that took place following the death of Cherylee, and the recommendations that were made as a result of those reviews, in particular centred on the lack of inter-agency communications. My concern is that despite this, and the findings of the report, when evidence was heard regarding how systems had changed, there is still no mandatory process for the sharing of information between agencies where the offender despite a known, and extensive, history of domestic abuse and identified trigger factors, is then managed at MAPPA Level 1.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 information during initial attendances on reported domestic abuse incidents
Wider context from the report “Following the death of Cherylee, her death, and actions taken in the months leading up to it were the subject of two detailed reviews. Following the Domestic Homicide Review a number of recommendations were made by the author of the Individual Management Report, Mr Gary Fishwick including concerns regarding initial grading of calls to identify initial responses, the obtaining of information as part of initial attendances on reported domestic abuse incidents and the carrying and use of personal protective equipment. Whilst the recommendations were made, Mr Fishwick could give no evidence at the inquest into the death of Cherylee to indicate whether those recommendations had in fact been actioned or not, and accordingly whether anything had changed following the death of Cherylee and the learning exercise that were subsequently undertaken.
In particular reference was made to, but unsupported by documentation, or any other form of evidence:
• Policies reflecting recommended changes;
• Information sharing agreements between agencies;
• MARAC emergency policy or notes;
• DASH Training or policy regarding obtaining GP details; and
• Audits of Grade 2 ‘Ethical fails’ and reasons for such fails.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Insufficient probation staffing capacity for complex and demanding casework
Wider context from the report “2) Evidence was further heard regarding the Report of the Chief Inspector of Probation 2019 and in particular the finding that "Many individuals were drifting through their supervision period without being challenged or supported to change their prediction for domestic abuse" and that "The number of probation professionals is now at a critical level . There is a national shortage of professional probation staff and especially those mainly responsible for more complex and demanding casework ". It was agreed by those senior probation witnesses that staffing and workloads had been an issue in this matter , as found by the jury, and furthermore continued to be so .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 evidence implementation of recommended safety changes
Wider context from the report “Following the death of Cherylee, her death, and actions taken in the months leading up to it were the subject of two detailed reviews. Following the Domestic Homicide Review a number of recommendations were made by the author of the Individual Management Report, Mr Gary Fishwick including concerns regarding initial grading of calls to identify initial responses, the obtaining of information as part of initial attendances on reported domestic abuse incidents and the carrying and use of personal protective equipment. Whilst the recommendations were made, Mr Fishwick could give no evidence at the inquest into the death of Cherylee to indicate whether those recommendations had in fact been actioned or not , and accordingly whether anything had changed following the death of Cherylee and the learning exercise that were subsequently undertaken.
In particular reference was made to, but unsupported by documentation, or any other form of evidence :
• Policies reflecting recommended changes;
• Information sharing agreements between agencies;
• MARAC emergency policy or notes;
• DASH Training or policy regarding obtaining GP details; and
• Audits of Grade 2 ‘Ethical fails’ and reasons for such fails.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 mandated joined-up inter-agency communication at offender release or when new personal relationships develop
Wider context from the report “1) During the course of the inquest statistics regarding the nature of domestic abuse were repeatedly reviewed and accepted by senior member of both probation and police services. In particular domestic abuse features in about half of all cases managed by probation staff and that in the year to the end of 2018 of the 659 homicides 1 in 10 were committed by a partner. Evidence was heard of the MAPPA process, for the managing of risk of offenders to be released on licence, and for the interagency sharing of information regarding those offenders. During the course of the evidence it was made clear that the perpetrator in this instance was a very dangerous individual, who was described as controlling and manipulative, and who, it was accepted by the witnesses involved in his management, was likely to have controlled his meetings by his nature, and by partial disclosures of information. The underlying issue that arose from both the various reviews that took place after the death of Cherylee Shennan, and from the inquest was that there was no substantial interagency communication following the perpetrator's release on licence , which would, the jury found, have allowed the sharing of his licence conditions and action plans to be put in place by local police forces. The jury concluded that such a failing possibly contributed to the death on the 17th March 2014. At the inquest no evidence was heard regarding any changes to MAPPA or the guidance given. Whilst the evidence heard was that the MAPPA level allocated to an individual is fluid, and would be based upon their risks and presentation at that time, my concern centres on the issue that an offender who has served a significant sentence and accordingly has never been fully tested before release on licence, and who has a significant history of domestic abuse and violence, will still be released on MAPPA level 1. On the evidence that was heard there remains no mandated process for joined up inter-agency working or communication at the point of their release, or when they develop new personal relationships .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Deficiencies in initial grading of calls to identify initial responses
Wider context from the report “Following the death of Cherylee, her death, and actions taken in the months leading up to it were the subject of two detailed reviews. Following the Domestic Homicide Review a number of recommendations were made by the author of the Individual Management Report, Mr Gary Fishwick including concerns regarding initial grading of calls to identify initial responses , the obtaining of information as part of initial attendances on reported domestic abuse incidents and the carrying and use of personal protective equipment. Whilst the recommendations were made, Mr Fishwick could give no evidence at the inquest into the death of Cherylee to indicate whether those recommendations had in fact been actioned or not, and accordingly whether anything had changed following the death of Cherylee and the learning exercise that were subsequently undertaken.
In particular reference was made to, but unsupported by documentation, or any other form of evidence:
• Policies reflecting recommended changes;
• Information sharing agreements between agencies;
• MARAC emergency policy or notes;
• DASH Training or policy regarding obtaining GP details; and
• Audits of Grade 2 ‘Ethical fails’ and reasons for such fails.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain mandatory inter-agency information sharing for MAPPA Level 1 management
Wider context from the report “The perpetrator was managed on release at MAPPA Level 1. Following his release there were no local MAPPA 1 meetings, no inter-agency meetings and no significant inter-agency communications regarding the perpetrator , no detailing of his licence conditions, and no information regarding either his nature or the trigger factors for his offending. Evidence was heard regarding the findings of two separate reviews that took place following the death of Cherylee, and the recommendations that were made as a result of those reviews, in particular centred on the lack of inter-agency communications . My concern is that despite this, and the findings of the report, when evidence was heard regarding how systems had changed, there is still no mandatory process for the sharing of information between agencies where the offender despite a known, and extensive, history of domestic abuse and identified trigger factors, is then managed at MAPPA Level 1.
” Open source report
Concerns raised 1 Lack of basic life support training for prison staff View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Darren McGuin · 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
Darren McGuin, a serving prisoner at HMP Lindholme, was found unresponsive in his cell on 22 February 2018 and later pronounced deceased. The report identified a delay in starting CPR because the prison officers present had not received basic life support training, and noted that some prison staff had never received such 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 basic life support training for prison staff
Wider context from the report “1) There was clearly a delay between Mr McGuin being found unresponsive by the prison officers and the commencement of CPR by members of the healthcare staff. Although, earlier CPR would not have altered the outcome in this particulate set of circumstances, it may on a different occasion.
2) Prison officers will usually be first on scene, particularly if a prisoner is found in their cell and this lack of basic life support training is leading to a delay in the commencement of CPR . The evidence before the Court was that prison officers who’s employment either started prior 2005 or after 2017, completed a compulsory three-day Basic Life Support and First Aid course as part of their mandatory training. However, at a date unknown at this time, this training requirement ceased. This inquest has highlighted that there are a number of staff working within the prison service who have never received basic life support training . It is my understanding that there are no efforts being made to identify and provide retrospective training to those members of staff who were appointed during this period of time where basic life support training was not provided.
The Ministry of State for Prisons is asked to consider whether it is appropriate for a review to take place to identify and subsequently provide appropriate basic life skill training to all prison staff, who have not received if as part of their mandatory training.
” Open source report
23 Jun 2019 Marcus William George McGuire · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 2 Failure of managers to maintain or communicate accurate information about ACCT improvements View source Failure to provide an embedded single case manager for each ACCT 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
Marcus William George McGuire · 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
Marcus William George McGuire died at HMP Birmingham on 24 April 2018 after being found in his cell with a ligature around his neck. The inquest concluded that his suicide was possibly contributed to by failures to carry out a mental health assessment, respond to missed anti-psychotic medication, involve mental health services in the ACCT process, assess his risk using all relevant information, and properly manage the ACCT.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure of managers to maintain or communicate accurate information about ACCT improvements
Wider context from the report “1. Many of the deficiencies in Mr. McGuire’s ACCT plan, such as the absence of a properly completed care plan, the failure to involve the mental health team, failure to consider all relevant and available information and failure to carry out an effective post-closure review, were attributable to the absence of an identified case manager which resulted in different members of staff chairing his case reviews and no-one taking responsibility to follow up on action points.
2. At the time of Mr. McGuire’s death it was not uncommon for ACCTs not to have an identified case manager.
3. Evidence was given at inquest that there has been an increase in the number of trained case managers to enable all ACCTs to have a designated single case manager who will remain the case manager for the life of the ACCT so far as reasonably possible and where a change is required, there is a formal hand-over process.
4. Following completion of the evidence, the Report on an independent review of progress at HMP Birmingham by H. M. Chief Inspector of Prisons based on an inspection of the 7th to 9th May 2019 was brought to my attention. Paragraph 2.27 of the report provides:
“The quality of ACCT casework was not yet good enough. In response to our concern at the last inspection, managers had sought to deliver single case management and provide prisoners in crisis with activities. This ambition has not yet been realised. None of the eight cases we checked had a single case manager...”
5. I am also aware that in a letter dated the 11th June 2019, ████████, Head of Custodial Contracts responded to the Report on the review of progress on behalf of H. M. Prison & Probation Service. In the response it is recognised that “we need to do more to embed single case management”.
6. I am concerned that I was given the impression that single case management is embedded at HMP Birmingham: if I had been aware that it was not, I would have sought additional evidence on why, what needed to be done to “embed” single case management and how it is intended to achieve it.
7. I am concerned that the disparity between the evidence given to me and the findings upon inspection 6 weeks earlier indicates that Managers at HMP Birmingham are either not aware of or not conveying the reality of the extent to which improvements in the ACCT process have been achieved.
8. The absence of an embedded system of single case management will put lives at risk as compliance with the ACCT process cannot be assured.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to provide an embedded single case manager for each ACCT
Wider context from the report “1. Many of the deficiencies in Mr. McGuire’s ACCT plan, such as the absence of a properly completed care plan, the failure to involve the mental health team, failure to consider all relevant and available information and failure to carry out an effective post-closure review, were attributable to the absence of an identified case manager which resulted in different members of staff chairing his case reviews and no-one taking responsibility to follow up on action points .
2. At the time of Mr. McGuire’s death it was not uncommon for ACCTs not to have an identified case manager .
3. Evidence was given at inquest that there has been an increase in the number of trained case managers to enable all ACCTs to have a designated single case manager who will remain the case manager for the life of the ACCT so far as reasonably possible and where a change is required, there is a formal hand-over process.
4. Following completion of the evidence, the Report on an independent review of progress at HMP Birmingham by H. M. Chief Inspector of Prisons based on an inspection of the 7th to 9th May 2019 was brought to my attention. Paragraph 2.27 of the report provides:
“The quality of ACCT casework was not yet good enough. In response to our concern at the last inspection, managers had sought to deliver single case management and provide prisoners in crisis with activities. This ambition has not yet been realised. None of the eight cases we checked had a single case manager... ”
5. I am also aware that in a letter dated the 11th June 2019, ████████, Head of Custodial Contracts responded to the Report on the review of progress on behalf of H. M. Prison & Probation Service. In the response it is recognised that “we need to do more to embed single case management ”.
6. I am concerned that I was given the impression that single case management is embedded at HMP Birmingham: if I had been aware that it was not, I would have sought additional evidence on why, what needed to be done to “embed” single case management and how it is intended to achieve it.
7. I am concerned that the disparity between the evidence given to me and the findings upon inspection 6 weeks earlier indicates that Managers at HMP Birmingham are either not aware of or not conveying the reality of the extent to which improvements in the ACCT process have been achieved.
8. The absence of an embedded system of single case management will put lives at risk as compliance with the ACCT process cannot be assured.
” Open source report
12 Jun 2019 Miss Nguyen Ngoc Quyen · Prevention of Future Deaths report Sunderland
View report summary
Concerns raised 9 Probation staffing and accommodation deficiencies View source Lack of integrated information technology View source Insufficient time and unsuitable environment for meaningful probation engagement View source Lack of contemporaneous probation computer records View source Over-reliance on offender self-reporting and ineffective challenge of accounts View source Failure to complete timely OASys risk and needs assessments View source Failure to share relevant police information with Probation View source Failures of communication across relevant sources View source Failure to monitor and actively manage Category 2 Level 1 offenders View source See 6 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
Miss Nguyen Ngoc Quyen · 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 Nguyen Ngoc Quyen died on 15 August 2017 at Success Road, Shiney Row, Houghton Le Spring; her death was consistent with the effects of fire. The report identified concerns about failures to act sufficiently, promptly and in a coordinated manner on known breaches of life licence conditions, including failures in information sharing between the Police and Probation Service, alongside wider organisational and supervision failings.
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 Probation staffing and accommodation deficiencies
Wider context from the report “The Inquest highlighted many other issues: -
• The Probation Service in Sunderland had staffing and accommodation problems. Operations and efficiency appeared to be in stark contrast between North West and North East.
• The time spent with ████████ was short and in a working environment not conducive to meaningful engagement.
• Unwin undermined the supervisory process by attending appointments with his child and not progressing in a more timely way the request to create a portfolio of his employment, culminating in an unsigned reference dated 25th July 2017.
• There were no contemporaneous computer records from 13th December 2016 until 18th August 2017, the day before ████████ appeared in Court for murder.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 integrated information technology
Wider context from the report “However, I remain concerned. For example, Probation were of the view that the present solution was an interim one, whereas the Police thought it was finalised.
There were further issues considered, such as the lack of integrated IT , failures of communication from a number of sources, supervision, issues of risk management and staff turnover, and pressures upon staff performance and the ability to investigate self-report.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Insufficient time and unsuitable environment for meaningful probation engagement
Wider context from the report “The Inquest highlighted many other issues: -
• The Probation Service in Sunderland had staffing and accommodation problems. Operations and efficiency appeared to be in stark contrast between North West and North East.
• The time spent with ████████ was short and in a working environment not conducive to meaningful engagement.
• Unwin undermined the supervisory process by attending appointments with his child and not progressing in a more timely way the request to create a portfolio of his employment, culminating in an unsigned reference dated 25th July 2017.
• There were no contemporaneous computer records from 13th December 2016 until 18th August 2017, the day before ████████ appeared in Court for murder.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 contemporaneous probation computer records
Wider context from the report “The Inquest highlighted many other issues: -
• The Probation Service in Sunderland had staffing and accommodation problems. Operations and efficiency appeared to be in stark contrast between North West and North East.
• The time spent with ████████ was short and in a working environment not conducive to meaningful engagement.
• Unwin undermined the supervisory process by attending appointments with his child and not progressing in a more timely way the request to create a portfolio of his employment, culminating in an unsigned reference dated 25th July 2017.
• There were no contemporaneous computer records from 13th December 2016 until 18th August 2017 , the day before ████████ appeared in Court for murder.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Over-reliance on offender self-reporting and ineffective challenge of accounts
Wider context from the report “There was an over reliance on self-reporting by the offenders. The evidence exposed a system for the protection of the public, which was at times dysfunctional, contributed to by human factors.
Evidence heard during the hearings demonstrated that there was a disconnect between the reality on the ground and, in particular, ████████’s accounts to his Probation Officer. Although inevitably he would minimise his actions, there was little or no evidence that he was challenged effectively .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 timely OASys risk and needs assessments
Wider context from the report “On the evidence, there were multiple occasions when information about ████████ could and should have been shared between the Police and Probation, and for him to be challenged in a more meaningful way than he was.
A Probation expert gave evidence about:
• the limitations of what can be achieved through the supervisory process;
• the frequency of the assessments in relation to ████████ appear to “have fallen below good practice standards” but had further reviews taken place, the risk assessments would not have changed;
• the absence of an Offender Assessment System (OASys) assessment on ████████ for over 3 years fell below good practice . Such an assessment would have assessed the risks and needs of an Offender;
• if Northumbria Police had passed on information to Probation about 2 incidents involving ████████ there would have been enforcement action, but short of recall as the threshold criteria had not been met.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 relevant police information with Probation
Wider context from the report “In April 2015 due to high operational demand there was a direction from the senior management team of Northumbria Police to stop monitoring Category 2 Level 1 offenders and to remove the markers on the log. As a result, the Multi Agency Public Protection Arrangements (MAPPA) department were no longer actively managing Category 2 Level 1 offenders. The responsibility for sharing information was solely with the sourcing officer. With ████████ his Police computer record was not updated , and attending Police Officers for incidents in 2015 and 2017 did not pass information to the relevant Probation Officer .
The responsibility goes wider though to Control Room Staff, Patrol Sergeants, Patrol Constables and Supervising Sergeants too, when markers, flags and warnings were evident.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failures of communication across relevant sources
Wider context from the report “However, I remain concerned. For example, Probation were of the view that the present solution was an interim one, whereas the Police thought it was finalised.
There were further issues considered, such as the lack of integrated IT, failures of communication from a number of sources , supervision, issues of risk management and staff turnover, and pressures upon staff performance and the ability to investigate self-report.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to monitor and actively manage Category 2 Level 1 offenders
Wider context from the report “In April 2015 due to high operational demand there was a direction from the senior management team of Northumbria Police to stop monitoring Category 2 Level 1 offenders and to remove the markers on the log . As a result, the Multi Agency Public Protection Arrangements (MAPPA) department were no longer actively managing Category 2 Level 1 offenders . The responsibility for sharing information was solely with the sourcing officer. With ████████ his Police computer record was not updated, and attending Police Officers for incidents in 2015 and 2017 did not pass information to the relevant Probation Officer.
The responsibility goes wider though to Control Room Staff, Patrol Sergeants, Patrol Constables and Supervising Sergeants too, when markers, flags and warnings were evident.
” Open source report
2 Apr 2019 Tarek Mahmood CHOWDHURY · Prevention of Future Deaths report West London
View report summary
Concerns raised 4 Inadequate operation of SystmOne when new detainees arrive at IRCs View source Failure to share prisoner information between HMPPS, DEPMU and IRC staff View source Inadequate training of nurses on SystmOne and related access issues View source Failure of the process authorising IRC nurses to access former prisoners’ records 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
Tarek Mahmood CHOWDHURY · 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
Tarek Mahmood CHOWDHURY was beaten to death by another detainee while detained at Heathrow Immigration Removal Centre on 1 December 2016. The report identified concerns about information sharing between prisons, the Home Office and immigration removal centres, including the availability of intelligence and other records. It also identified concerns about access to and operation of SystmOne healthcare records during the initial screening of detainees transferred from prison.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Inadequate operation of SystmOne when new detainees arrive at IRCs
Wider context from the report “(2) That SystmOne is not operating adequately when new detainees arrive at IRCs . There are concerns both about the technology itself of SystmOne ; about the process of authorising a nurse in an IRC to see records of a former prisoner; and about whether trainers are able adequately to train nurses in respect of these issues. These concerns are addressed to NHS England, which is understood to commission and supply SystmOne; and to TPP, which is the technology company which is understood to have developed SystmOne.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 prisoner information between HMPPS, DEPMU and IRC staff
Wider context from the report “(1) That there is a failure to share information about prisoners who are to become detainees, between HMPPS and the Home Office’s DEPMU, and between HMPPS and staff in IRCs . The rolling out of Mercury intelligence to DEPMU/IRCs will not solve this problem if other information (in particular NOMIS and OASYS) is still not available to DEPMU/IRCs . This concern is addressed both to the Ministry of Justice (HMPPS) and to the Home Office (DEPMU/IRCs).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 training of nurses on SystmOne and related access issues
Wider context from the report “(2) That SystmOne is not operating adequately when new detainees arrive at IRCs. There are concerns both about the technology itself of SystmOne; about the process of authorising a nurse in an IRC to see records of a former prisoner; and about whether trainers are able adequately to train nurses in respect of these issues . These concerns are addressed to NHS England, which is understood to commission and supply SystmOne; and to TPP, which is the technology company which is understood to have developed SystmOne.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 process authorising IRC nurses to access former prisoners’ records
Wider context from the report “(2) That SystmOne is not operating adequately when new detainees arrive at IRCs. There are concerns both about the technology itself of SystmOne; about the process of authorising a nurse in an IRC to see records of a former prisoner ; and about whether trainers are able adequately to train nurses in respect of these issues. These concerns are addressed to NHS England, which is understood to commission and supply SystmOne; and to TPP, which is the technology company which is understood to have developed SystmOne.
” Open source report
26 Feb 2019 Christopher Andrew MOSS · Prevention of Future Deaths report Staffordshire South
View report summary
Concerns raised 1 Lack of appropriately located equipment for barricade situations involving non-dual-opening cell doors View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Christopher Andrew MOSS · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Christopher Andrew MOSS was a serving prisoner at HMP Featherstone who died on 18 February 2017 from a self-inflicted incision to his left wrist. The principal concern was that appropriate equipment was not initially available to open the cell door during the barricade incident, raising a concern about whether prisons should check that suitable equipment is available for their particular doors.
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 appropriately located equipment for barricade situations involving non-dual-opening cell doors
Wider context from the report “At the incident when Christopher died initially a hydraulic jack to open the cell door was summoned to the scene when the appropriate equipment was not available (it did in fact arrive very soon afterwards). I am aware that there is a gradual process in the prison estate to move towards cell doors that can be opened outwards if necessary in addition to normally opening inwards. My concern however is that for doors that are not dual opening prisons should have appropriate equipment available to deal with barricade situations . Should there be a check or audit to ensure that the correct equipment for the relevant doors are located appropriately at prisons ?
” Open source report
31 Jan 2019 Andrew Stephen Carr · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 4 Failure to prevent drugs and other items being passed through the prison plumbing system View source Failure to record information about prisoner substance misuse and drug-related intelligence View source Uncontrolled use of contraband mobile phones contributing to substance misuse problems View source Failure to review information about prisoners entering the prison 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
Andrew Stephen Carr · 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
Andrew Stephen Carr, a prisoner, was found unresponsive in his cell on 29 March 2018 and was pronounced dead at 22:53 after attempts to revive him were unsuccessful. The medical cause of death was recorded as the effects of a synthetic cannabinoid. Concerns included failures to identify and record information about his prior substance use, the known use of the prison plumbing system to pass drugs, and the role of contraband mobile phones in substance misuse.
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 drugs and other items being passed through the prison plumbing system
Wider context from the report “2. It had been known for approximately 5 years that drugs and other items could be passed through the plumbing system of the prison . No action was taken before Andrew’s death and the inquest heard that no solution had been found to the problem . This raises an ongoing concern for the wellbeing of prisoners and the risk of future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to record information about prisoner substance misuse and drug-related intelligence
Wider context from the report “1. The inquest heard evidence that before his transfer to Birmingham prison on 19/02/18 Andrew had been involved in 4 incidents of taking psychoactive substances resulting in a code blue being called. In addition there was intelligence that he may be giving out drugs. This information was available and passed onto Birmingham Prison - however they were not aware of it and did not record the information . The inquest heard that there was no time to review information of prisoners coming into the prison. This is a major concern as key information may not be identified and this poses a risk to the individual and other prisoners.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Uncontrolled use of contraband mobile phones contributing to substance misuse problems
Wider context from the report “3. Many problems within the prison related to substances misuse are contributed to by the use of contraband mobile phones . The inquest heard evidence that blocking the use of mobile phones in prison would be very useful in mitigating this 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 to review information about prisoners entering the prison
Wider context from the report “1. The inquest heard evidence that before his transfer to Birmingham prison on 19/02/18 Andrew had been involved in 4 incidents of taking psychoactive substances resulting in a code blue being called. In addition there was intelligence that he may be giving out drugs. This information was available and passed onto Birmingham Prison - however they were not aware of it and did not record the information. The inquest heard that there was no time to review information of prisoners coming into the prison . This is a major concern as key information may not be identified and this poses a risk to the individual and other prisoners.
” Open source report
11 Jan 2019 Ricardo Wayne Holgate · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 4 Lack of CCTV coverage on all prison wings View source Failure to adequately manage illicit substance misuse in the prison View source Unavailability of airport-style scanners at prisoner reception and the visitor area View source Failure to prevent the use and supply of illicit substances in the prison 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
Ricardo Wayne Holgate · 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
Ricardo Wayne Holgate was found dead in his cell at Birmingham Prison on the morning of 26 March 2018. The post-mortem recorded coronary artery thrombosis and atherosclerosis, with the combined effects of synthetic cannabinoid and codeine. The inquest identified significant concerns about the supply and use of illicit substances, staffing levels, staff training and experience, and inconsistent management and reporting of prisoners affected by such substances.
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 CCTV coverage on all prison wings
Wider context from the report “1. The new Governing Governor confirmed that further steps are necessary to improve the management of illicit substance misuse. He confirmed the prison requires CCTV on all wings and airport style scanners – one in reception for prisoners and one in the visitor area.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to adequately manage illicit substance misuse in the prison
Wider context from the report “1. The new Governing Governor confirmed that further steps are necessary to improve the management of illicit substance misuse . He confirmed the prison requires CCTV on all wings and airport style scanners – one in reception for prisoners and one in the visitor area.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 airport-style scanners at prisoner reception and the visitor area
Wider context from the report “1. The new Governing Governor confirmed that further steps are necessary to improve the management of illicit substance misuse. He confirmed the prison requires CCTV on all wings and airport style scanners – one in reception for prisoners and one in the visitor area .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 the use and supply of illicit substances in the prison
Wider context from the report “2. Much progress has been made as a result of the appointment of the Governing Governor Paul Newton. His appointment was for 6 months. He advised at the inquest that there is much more work to do and extension of his appointment would allow further work to be undertaken to reduce the use and supply of illicit substances in the prison and to keep inmates safe.
” Open source report
10 Jan 2019 Natasha Learline CHIN · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 12 Lack of audit of opiate and alcohol withdrawal observations View source Inadequate training on opiate and alcohol withdrawal signs and dangers View source Failure to make datix referrals for missed medications View source Unclear governance for non-administration of prescribed medication View source Unclear and incomplete protocols for opiate and alcohol withdrawal View source Lack of audit of on-time administration of critical medication View source Lack of verification that medication safety matters have been adequately addressed View source Inadequate training of clinical staff in completing withdrawal scales View source Lack of audit of nurse prescribing and pre-prescription record checks View source Lack of audit of medical-record accuracy on System 1 View source Lack of follow-up and recording of prescribed medication non-attendance View source Lack of medication information sharing with discipline staff 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
Natasha Learline CHIN · 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
Natasha Learline Chin died in her cell at HMP Bronzefield on 19 July 2016 after profuse vomiting associated with undertreated opiate and alcohol withdrawal. The report identified concerns about delayed medication, inadequate monitoring and escalation, failures in record-keeping and governance, and insufficient auditing and 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 audit of opiate and alcohol withdrawal observations
Wider context from the report “1. The prison officer with responsibility for the wing on which Miss Chin was resident was not privy to what medication she was prescribed nor when it should be administered. There is no system in place for consent to be obtained from prisoners for this information to be shared with discipline staff.
2. The Sodexo Justice Service Protocols in respect of opiate and alcohol withdrawal did not adequately mirror the National Protocols and were, in parts, unclear and difficult to comprehend.
3. Nurses failed to make any datix referrals in respect of missed medications.
4. The following matters have to date not been formally audited by Sodexo Justice Services:
i.) Whether prisoners who do not attend for prescribed medications are followed up and the reason for non-attendance is properly recorded.
ii.) Whether critical medication is administered on time.
iii.) Whether proper observations are undertaken in line with national or local protocols in respect of opiate and alcohol withdrawal.
iv.) Whether medical records on System 1 are accurately recorded.
v.) Whether the Patient Guidance Directions in respect of prescribing by nurses are adhered to, and whether medical records are checked before any prescriptions are made by nurses pursuant to the directive.
5. As a consequence it is not possible for Sodexo Justice Services to know whether the matters raised in 4.(i) to (v) have been adequately addressed.
6. The response by Sodexo Justice Services to the issues identified in the report dated the 13th April 2016 of Her Majesty’s Chief Inspector of Prisons in respect of non-administration of prescribed medication was inadequate. It does not appear that there was a clear line of governance in respect of this matter.
7. Whether there is adequate training:
i.) of discipline and clinical staff, including agency staff, to make them aware of the signs and dangers of opiate and alcohol withdrawal.
ii.) of clinical staff in respect of the completion of opiate and alcohol withdrawal scales.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 training on opiate and alcohol withdrawal signs and dangers
Wider context from the report “1. The prison officer with responsibility for the wing on which Miss Chin was resident was not privy to what medication she was prescribed nor when it should be administered. There is no system in place for consent to be obtained from prisoners for this information to be shared with discipline staff.
2. The Sodexo Justice Service Protocols in respect of opiate and alcohol withdrawal did not adequately mirror the National Protocols and were, in parts, unclear and difficult to comprehend.
3. Nurses failed to make any datix referrals in respect of missed medications.
4. The following matters have to date not been formally audited by Sodexo Justice Services:
i.) Whether prisoners who do not attend for prescribed medications are followed up and the reason for non-attendance is properly recorded.
ii.) Whether critical medication is administered on time.
iii.) Whether proper observations are undertaken in line with national or local protocols in respect of opiate and alcohol withdrawal.
iv.) Whether medical records on System 1 are accurately recorded.
v.) Whether the Patient Guidance Directions in respect of prescribing by nurses are adhered to, and whether medical records are checked before any prescriptions are made by nurses pursuant to the directive.
5. As a consequence it is not possible for Sodexo Justice Services to know whether the matters raised in 4.(i) to (v) have been adequately addressed.
6. The response by Sodexo Justice Services to the issues identified in the report dated the 13th April 2016 of Her Majesty’s Chief Inspector of Prisons in respect of non-administration of prescribed medication was inadequate. It does not appear that there was a clear line of governance in respect of this matter.
7. Whether there is adequate training:
i.) of discipline and clinical staff, including agency staff, to make them aware of the signs and dangers of opiate and alcohol withdrawal.
ii.) of clinical staff in respect of the completion of opiate and alcohol withdrawal scales.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to make datix referrals for missed medications
Wider context from the report “1. The prison officer with responsibility for the wing on which Miss Chin was resident was not privy to what medication she was prescribed nor when it should be administered. There is no system in place for consent to be obtained from prisoners for this information to be shared with discipline staff.
2. The Sodexo Justice Service Protocols in respect of opiate and alcohol withdrawal did not adequately mirror the National Protocols and were, in parts, unclear and difficult to comprehend.
3. Nurses failed to make any datix referrals in respect of missed medications.
4. The following matters have to date not been formally audited by Sodexo Justice Services:
i.) Whether prisoners who do not attend for prescribed medications are followed up and the reason for non-attendance is properly recorded.
ii.) Whether critical medication is administered on time.
iii.) Whether proper observations are undertaken in line with national or local protocols in respect of opiate and alcohol withdrawal.
iv.) Whether medical records on System 1 are accurately recorded.
v.) Whether the Patient Guidance Directions in respect of prescribing by nurses are adhered to, and whether medical records are checked before any prescriptions are made by nurses pursuant to the directive.
5. As a consequence it is not possible for Sodexo Justice Services to know whether the matters raised in 4.(i) to (v) have been adequately addressed.
6. The response by Sodexo Justice Services to the issues identified in the report dated the 13th April 2016 of Her Majesty’s Chief Inspector of Prisons in respect of non-administration of prescribed medication was inadequate. It does not appear that there was a clear line of governance in respect of this matter.
7. Whether there is adequate training:
i.) of discipline and clinical staff, including agency staff, to make them aware of the signs and dangers of opiate and alcohol withdrawal.
ii.) of clinical staff in respect of the completion of opiate and alcohol withdrawal scales.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 governance for non-administration of prescribed medication
Wider context from the report “1. The prison officer with responsibility for the wing on which Miss Chin was resident was not privy to what medication she was prescribed nor when it should be administered. There is no system in place for consent to be obtained from prisoners for this information to be shared with discipline staff.
2. The Sodexo Justice Service Protocols in respect of opiate and alcohol withdrawal did not adequately mirror the National Protocols and were, in parts, unclear and difficult to comprehend.
3. Nurses failed to make any datix referrals in respect of missed medications.
4. The following matters have to date not been formally audited by Sodexo Justice Services:
i.) Whether prisoners who do not attend for prescribed medications are followed up and the reason for non-attendance is properly recorded.
ii.) Whether critical medication is administered on time.
iii.) Whether proper observations are undertaken in line with national or local protocols in respect of opiate and alcohol withdrawal.
iv.) Whether medical records on System 1 are accurately recorded.
v.) Whether the Patient Guidance Directions in respect of prescribing by nurses are adhered to, and whether medical records are checked before any prescriptions are made by nurses pursuant to the directive.
5. As a consequence it is not possible for Sodexo Justice Services to know whether the matters raised in 4.(i) to (v) have been adequately addressed.
6. The response by Sodexo Justice Services to the issues identified in the report dated the 13th April 2016 of Her Majesty’s Chief Inspector of Prisons in respect of non-administration of prescribed medication was inadequate. It does not appear that there was a clear line of governance in respect of this matter.
7. Whether there is adequate training:
i.) of discipline and clinical staff, including agency staff, to make them aware of the signs and dangers of opiate and alcohol withdrawal.
ii.) of clinical staff in respect of the completion of opiate and alcohol withdrawal scales.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Unclear and incomplete protocols for opiate and alcohol withdrawal
Wider context from the report “1. The prison officer with responsibility for the wing on which Miss Chin was resident was not privy to what medication she was prescribed nor when it should be administered. There is no system in place for consent to be obtained from prisoners for this information to be shared with discipline staff.
2. The Sodexo Justice Service Protocols in respect of opiate and alcohol withdrawal did not adequately mirror the National Protocols and were, in parts, unclear and difficult to comprehend.
3. Nurses failed to make any datix referrals in respect of missed medications.
4. The following matters have to date not been formally audited by Sodexo Justice Services:
i.) Whether prisoners who do not attend for prescribed medications are followed up and the reason for non-attendance is properly recorded.
ii.) Whether critical medication is administered on time.
iii.) Whether proper observations are undertaken in line with national or local protocols in respect of opiate and alcohol withdrawal.
iv.) Whether medical records on System 1 are accurately recorded.
v.) Whether the Patient Guidance Directions in respect of prescribing by nurses are adhered to, and whether medical records are checked before any prescriptions are made by nurses pursuant to the directive.
5. As a consequence it is not possible for Sodexo Justice Services to know whether the matters raised in 4.(i) to (v) have been adequately addressed.
6. The response by Sodexo Justice Services to the issues identified in the report dated the 13th April 2016 of Her Majesty’s Chief Inspector of Prisons in respect of non-administration of prescribed medication was inadequate. It does not appear that there was a clear line of governance in respect of this matter.
7. Whether there is adequate training:
i.) of discipline and clinical staff, including agency staff, to make them aware of the signs and dangers of opiate and alcohol withdrawal.
ii.) of clinical staff in respect of the completion of opiate and alcohol withdrawal scales.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 audit of on-time administration of critical medication
Wider context from the report “1. The prison officer with responsibility for the wing on which Miss Chin was resident was not privy to what medication she was prescribed nor when it should be administered. There is no system in place for consent to be obtained from prisoners for this information to be shared with discipline staff.
2. The Sodexo Justice Service Protocols in respect of opiate and alcohol withdrawal did not adequately mirror the National Protocols and were, in parts, unclear and difficult to comprehend.
3. Nurses failed to make any datix referrals in respect of missed medications.
4. The following matters have to date not been formally audited by Sodexo Justice Services:
i.) Whether prisoners who do not attend for prescribed medications are followed up and the reason for non-attendance is properly recorded.
ii.) Whether critical medication is administered on time.
iii.) Whether proper observations are undertaken in line with national or local protocols in respect of opiate and alcohol withdrawal.
iv.) Whether medical records on System 1 are accurately recorded.
v.) Whether the Patient Guidance Directions in respect of prescribing by nurses are adhered to, and whether medical records are checked before any prescriptions are made by nurses pursuant to the directive.
5. As a consequence it is not possible for Sodexo Justice Services to know whether the matters raised in 4.(i) to (v) have been adequately addressed.
6. The response by Sodexo Justice Services to the issues identified in the report dated the 13th April 2016 of Her Majesty’s Chief Inspector of Prisons in respect of non-administration of prescribed medication was inadequate. It does not appear that there was a clear line of governance in respect of this matter.
7. Whether there is adequate training:
i.) of discipline and clinical staff, including agency staff, to make them aware of the signs and dangers of opiate and alcohol withdrawal.
ii.) of clinical staff in respect of the completion of opiate and alcohol withdrawal scales.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 verification that medication safety matters have been adequately addressed
Wider context from the report “1. The prison officer with responsibility for the wing on which Miss Chin was resident was not privy to what medication she was prescribed nor when it should be administered. There is no system in place for consent to be obtained from prisoners for this information to be shared with discipline staff.
2. The Sodexo Justice Service Protocols in respect of opiate and alcohol withdrawal did not adequately mirror the National Protocols and were, in parts, unclear and difficult to comprehend.
3. Nurses failed to make any datix referrals in respect of missed medications.
4. The following matters have to date not been formally audited by Sodexo Justice Services:
i.) Whether prisoners who do not attend for prescribed medications are followed up and the reason for non-attendance is properly recorded.
ii.) Whether critical medication is administered on time.
iii.) Whether proper observations are undertaken in line with national or local protocols in respect of opiate and alcohol withdrawal.
iv.) Whether medical records on System 1 are accurately recorded.
v.) Whether the Patient Guidance Directions in respect of prescribing by nurses are adhered to, and whether medical records are checked before any prescriptions are made by nurses pursuant to the directive.
5. As a consequence it is not possible for Sodexo Justice Services to know whether the matters raised in 4.(i) to (v) have been adequately addressed.
6. The response by Sodexo Justice Services to the issues identified in the report dated the 13th April 2016 of Her Majesty’s Chief Inspector of Prisons in respect of non-administration of prescribed medication was inadequate. It does not appear that there was a clear line of governance in respect of this matter.
7. Whether there is adequate training:
i.) of discipline and clinical staff, including agency staff, to make them aware of the signs and dangers of opiate and alcohol withdrawal.
ii.) of clinical staff in respect of the completion of opiate and alcohol withdrawal scales.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 training of clinical staff in completing withdrawal scales
Wider context from the report “1. The prison officer with responsibility for the wing on which Miss Chin was resident was not privy to what medication she was prescribed nor when it should be administered. There is no system in place for consent to be obtained from prisoners for this information to be shared with discipline staff.
2. The Sodexo Justice Service Protocols in respect of opiate and alcohol withdrawal did not adequately mirror the National Protocols and were, in parts, unclear and difficult to comprehend.
3. Nurses failed to make any datix referrals in respect of missed medications.
4. The following matters have to date not been formally audited by Sodexo Justice Services:
i.) Whether prisoners who do not attend for prescribed medications are followed up and the reason for non-attendance is properly recorded.
ii.) Whether critical medication is administered on time.
iii.) Whether proper observations are undertaken in line with national or local protocols in respect of opiate and alcohol withdrawal.
iv.) Whether medical records on System 1 are accurately recorded.
v.) Whether the Patient Guidance Directions in respect of prescribing by nurses are adhered to, and whether medical records are checked before any prescriptions are made by nurses pursuant to the directive.
5. As a consequence it is not possible for Sodexo Justice Services to know whether the matters raised in 4.(i) to (v) have been adequately addressed.
6. The response by Sodexo Justice Services to the issues identified in the report dated the 13th April 2016 of Her Majesty’s Chief Inspector of Prisons in respect of non-administration of prescribed medication was inadequate. It does not appear that there was a clear line of governance in respect of this matter.
7. Whether there is adequate training:
i.) of discipline and clinical staff, including agency staff, to make them aware of the signs and dangers of opiate and alcohol withdrawal.
ii.) of clinical staff in respect of the completion of opiate and alcohol withdrawal scales.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 audit of nurse prescribing and pre-prescription record checks
Wider context from the report “1. The prison officer with responsibility for the wing on which Miss Chin was resident was not privy to what medication she was prescribed nor when it should be administered. There is no system in place for consent to be obtained from prisoners for this information to be shared with discipline staff.
2. The Sodexo Justice Service Protocols in respect of opiate and alcohol withdrawal did not adequately mirror the National Protocols and were, in parts, unclear and difficult to comprehend.
3. Nurses failed to make any datix referrals in respect of missed medications.
4. The following matters have to date not been formally audited by Sodexo Justice Services:
i.) Whether prisoners who do not attend for prescribed medications are followed up and the reason for non-attendance is properly recorded.
ii.) Whether critical medication is administered on time.
iii.) Whether proper observations are undertaken in line with national or local protocols in respect of opiate and alcohol withdrawal.
iv.) Whether medical records on System 1 are accurately recorded.
v.) Whether the Patient Guidance Directions in respect of prescribing by nurses are adhered to, and whether medical records are checked before any prescriptions are made by nurses pursuant to the directive.
5. As a consequence it is not possible for Sodexo Justice Services to know whether the matters raised in 4.(i) to (v) have been adequately addressed.
6. The response by Sodexo Justice Services to the issues identified in the report dated the 13th April 2016 of Her Majesty’s Chief Inspector of Prisons in respect of non-administration of prescribed medication was inadequate. It does not appear that there was a clear line of governance in respect of this matter.
7. Whether there is adequate training:
i.) of discipline and clinical staff, including agency staff, to make them aware of the signs and dangers of opiate and alcohol withdrawal.
ii.) of clinical staff in respect of the completion of opiate and alcohol withdrawal scales.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 audit of medical-record accuracy on System 1
Wider context from the report “1. The prison officer with responsibility for the wing on which Miss Chin was resident was not privy to what medication she was prescribed nor when it should be administered. There is no system in place for consent to be obtained from prisoners for this information to be shared with discipline staff.
2. The Sodexo Justice Service Protocols in respect of opiate and alcohol withdrawal did not adequately mirror the National Protocols and were, in parts, unclear and difficult to comprehend.
3. Nurses failed to make any datix referrals in respect of missed medications.
4. The following matters have to date not been formally audited by Sodexo Justice Services:
i.) Whether prisoners who do not attend for prescribed medications are followed up and the reason for non-attendance is properly recorded.
ii.) Whether critical medication is administered on time.
iii.) Whether proper observations are undertaken in line with national or local protocols in respect of opiate and alcohol withdrawal.
iv.) Whether medical records on System 1 are accurately recorded.
v.) Whether the Patient Guidance Directions in respect of prescribing by nurses are adhered to, and whether medical records are checked before any prescriptions are made by nurses pursuant to the directive.
5. As a consequence it is not possible for Sodexo Justice Services to know whether the matters raised in 4.(i) to (v) have been adequately addressed.
6. The response by Sodexo Justice Services to the issues identified in the report dated the 13th April 2016 of Her Majesty’s Chief Inspector of Prisons in respect of non-administration of prescribed medication was inadequate. It does not appear that there was a clear line of governance in respect of this matter.
7. Whether there is adequate training:
i.) of discipline and clinical staff, including agency staff, to make them aware of the signs and dangers of opiate and alcohol withdrawal.
ii.) of clinical staff in respect of the completion of opiate and alcohol withdrawal scales.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 follow-up and recording of prescribed medication non-attendance
Wider context from the report “1. The prison officer with responsibility for the wing on which Miss Chin was resident was not privy to what medication she was prescribed nor when it should be administered. There is no system in place for consent to be obtained from prisoners for this information to be shared with discipline staff.
2. The Sodexo Justice Service Protocols in respect of opiate and alcohol withdrawal did not adequately mirror the National Protocols and were, in parts, unclear and difficult to comprehend.
3. Nurses failed to make any datix referrals in respect of missed medications.
4. The following matters have to date not been formally audited by Sodexo Justice Services:
i.) Whether prisoners who do not attend for prescribed medications are followed up and the reason for non-attendance is properly recorded.
ii.) Whether critical medication is administered on time.
iii.) Whether proper observations are undertaken in line with national or local protocols in respect of opiate and alcohol withdrawal.
iv.) Whether medical records on System 1 are accurately recorded.
v.) Whether the Patient Guidance Directions in respect of prescribing by nurses are adhered to, and whether medical records are checked before any prescriptions are made by nurses pursuant to the directive.
5. As a consequence it is not possible for Sodexo Justice Services to know whether the matters raised in 4.(i) to (v) have been adequately addressed.
6. The response by Sodexo Justice Services to the issues identified in the report dated the 13th April 2016 of Her Majesty’s Chief Inspector of Prisons in respect of non-administration of prescribed medication was inadequate. It does not appear that there was a clear line of governance in respect of this matter.
7. Whether there is adequate training:
i.) of discipline and clinical staff, including agency staff, to make them aware of the signs and dangers of opiate and alcohol withdrawal.
ii.) of clinical staff in respect of the completion of opiate and alcohol withdrawal scales.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 medication information sharing with discipline staff
Wider context from the report “1. The prison officer with responsibility for the wing on which Miss Chin was resident was not privy to what medication she was prescribed nor when it should be administered. There is no system in place for consent to be obtained from prisoners for this information to be shared with discipline staff.
2. The Sodexo Justice Service Protocols in respect of opiate and alcohol withdrawal did not adequately mirror the National Protocols and were, in parts, unclear and difficult to comprehend.
3. Nurses failed to make any datix referrals in respect of missed medications.
4. The following matters have to date not been formally audited by Sodexo Justice Services:
i.) Whether prisoners who do not attend for prescribed medications are followed up and the reason for non-attendance is properly recorded.
ii.) Whether critical medication is administered on time.
iii.) Whether proper observations are undertaken in line with national or local protocols in respect of opiate and alcohol withdrawal.
iv.) Whether medical records on System 1 are accurately recorded.
v.) Whether the Patient Guidance Directions in respect of prescribing by nurses are adhered to, and whether medical records are checked before any prescriptions are made by nurses pursuant to the directive.
5. As a consequence it is not possible for Sodexo Justice Services to know whether the matters raised in 4.(i) to (v) have been adequately addressed.
6. The response by Sodexo Justice Services to the issues identified in the report dated the 13th April 2016 of Her Majesty’s Chief Inspector of Prisons in respect of non-administration of prescribed medication was inadequate. It does not appear that there was a clear line of governance in respect of this matter.
7. Whether there is adequate training:
i.) of discipline and clinical staff, including agency staff, to make them aware of the signs and dangers of opiate and alcohol withdrawal.
ii.) of clinical staff in respect of the completion of opiate and alcohol withdrawal scales.
” Open source report
19 Dec 2018 Michal Piotr Netyks · Prevention of Future Deaths report Liverpool and the Wirral
View report summary
Concerns raised 8 Deletion of immigration-detention records to prevent accurate death-in-detention statistics View source Failure to verify Treaty-rights evidence with employers or HMRC during deportation appeals View source Failure to review first-floor mezzanine railing and fall-protection design View source Failure to provide deportation documentation in a form understandable to subjects with limited written English View source Lack of deportation-process training for prison custody officers serving deportation documentation View source Incomplete disclosure of casework notes to the inquest View source Lack of access to duty-lawyer immigration advice for deportable foreign national prisoners outside immigration detention centres View source Unavailability of a senior Home Office manager for procedural liaison during inquests View source See 5 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
Michal Piotr Netyks · 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
Michal Piotr Netyks, a Polish national serving a custodial sentence at HMP Altcourse, died after jumping head first from first-floor railings on 7 December 2017, the day he was due to be released but was instead detained under immigration powers. The report identifies concerns about the timing and explanation of the immigration detention paperwork, access to legal advice and support, the prison railings, and aspects of the Home Office’s handling of the case.
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 Deletion of immigration-detention records to prevent accurate death-in-detention statistics
Wider context from the report “E. On the sixth day of evidence, the Home Office disclosed partially redacted casework (CID) notes but only from 31st October 2017 to 5th November 2018. The entry on 5th November is of the greatest concern given the duty of candour and integrity expected from Government and its Civil servants. The Home Office was made an interested person to protect its rights but also to assist the court. The following entry needs investigation and an explanation as its effect is to manipulate statistics – it appears to be almost a denial of the facts...
“Hi, Name:
Michal Netyks
DOB:
10 Aug 1982
Nationality:
POL
Gender:
M
System:
CID
Notes
Created:05 Nov 2018Created by:M2CAT0Unit:CCD Ops GeType:CASE
Due to the sensitive nature of this case, senior management have taken the decision to make an exception with this case and delete the record indicating Mr Netyks was IS detained from 07.12.17 . This is to prevent MI inadvertently recording this case as a death in immigration detention as Mr Netyks was still serving his custodial sentence at the time of his death. To ensure there are no gaps between the actual time of release from the HMP, current processes are in place to consider and serve detention paperwork in advance of the CRD and to then update the Restriction screen indicating the foreign national offender will be IS detained on the same date of CRD. These actions minimises the risk of release without consideration. Monica Cato Data Analysis & Management Information Team (DAMIT) Criminal Casework Secretariat Tel: ████████
Created:28 Aug 2018Created by:S11TAYLORUnit:Litig Ops Type:CASE
Death in Custody case update: Inquest to be listed”
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to verify Treaty-rights evidence with employers or HMRC during deportation appeals
Wider context from the report “D. In this inquest the Home Office were given the status of interested persons from an early stage. The Court has been greatly assisted by counsel and instructing solicitors acting for the department along with two witnesses. It was evident and unhelpful that the Home Office did not have a senior manager present throughout the proceedings to assist the court on procedures, if only by way of liaison. The inquest is not an immigration appeal tribunal and yet on evidence received it is more likely than not that Mr Netyks was exercising Treaty rights through employment and family life in North Wales. It appeared unfair that an incarcerated subject of the deportation process was required to provide evidence of the exercise of Treaty rights when the Home Office Caseworker could easily have made a check with the employer or HMRC for corroboration of his appeal against the stage one process . This is particularly concerning given English was a second language and all documentation was only provided in English. The facility to appear to speak and understand English is not the same as being able to comprehend the written word. This apparent unfairness could be addressed by the issue in B above, or by immigration officers explaining such documentation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to review first-floor mezzanine railing and fall-protection design
Wider context from the report “C. Evidence was received from the Ministry of Justice that the safety considerations from the first floor mezzanine level complied with HMPPS standards. The witness indicated in the witness box that he had never seen the design of the railings at HMP Altcourse before and would be reviewing the first floor Mezzanine safety for this design of Prison . The Court seeks confirmation of this review covering both railings and netting as options. (The Court heard that netting would be problematic given the easy access both from above and below – leading to disruption for the prison).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to provide deportation documentation in a form understandable to subjects with limited written English
Wider context from the report “D. In this inquest the Home Office were given the status of interested persons from an early stage. The Court has been greatly assisted by counsel and instructing solicitors acting for the department along with two witnesses. It was evident and unhelpful that the Home Office did not have a senior manager present throughout the proceedings to assist the court on procedures, if only by way of liaison. The inquest is not an immigration appeal tribunal and yet on evidence received it is more likely than not that Mr Netyks was exercising Treaty rights through employment and family life in North Wales. It appeared unfair that an incarcerated subject of the deportation process was required to provide evidence of the exercise of Treaty rights when the Home Office Caseworker could easily have made a check with the employer or HMRC for corroboration of his appeal against the stage one process. This is particularly concerning given English was a second language and all documentation was only provided in English . The facility to appear to speak and understand English is not the same as being able to comprehend the written word . This apparent unfairness could be addressed by the issue in B above, or by immigration officers explaining such documentation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 deportation-process training for prison custody officers serving deportation documentation
Wider context from the report “A. Under PSI 52/2011 Annex K Prison Custody Officers (PCO) are to only act as a postman without giving advice when serving papers related to deportation. The Court heard that PCO do not give legal advice but often have to explain the effect of such documentation such as the authority to further detain IS91 (which in this case had to be delivered before a IS91R was received by the prison). Documentation is served without an immigration Officer present and those charged with this role would be more effective if they were provided with a training package, making them aware of the deportation process . The Court is of the view that only the Home Office can deliver this training.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Incomplete disclosure of casework notes to the inquest
Wider context from the report “E. On the sixth day of evidence, the Home Office disclosed partially redacted casework (CID) notes but only from 31st October 2017 to 5th November 2018 . The entry on 5th November is of the greatest concern given the duty of candour and integrity expected from Government and its Civil servants. The Home Office was made an interested person to protect its rights but also to assist the court. The following entry needs investigation and an explanation as its effect is to manipulate statistics – it appears to be almost a denial of the facts...
“Hi, Name:
Michal Netyks
DOB:
10 Aug 1982
Nationality:
POL
Gender:
M
System:
CID
Notes
Created:05 Nov 2018Created by:M2CAT0Unit:CCD Ops GeType:CASE
Due to the sensitive nature of this case, senior management have taken the decision to make an exception with this case and delete the record indicating Mr Netyks was IS detained from 07.12.17. This is to prevent MI inadvertently recording this case as a death in immigration detention as Mr Netyks was still serving his custodial sentence at the time of his death. To ensure there are no gaps between the actual time of release from the HMP, current processes are in place to consider and serve detention paperwork in advance of the CRD and to then update the Restriction screen indicating the foreign national offender will be IS detained on the same date of CRD. These actions minimises the risk of release without consideration. Monica Cato Data Analysis & Management Information Team (DAMIT) Criminal Casework Secretariat Tel: ████████
Created:28 Aug 2018Created by:S11TAYLORUnit:Litig Ops Type:CASE
Death in Custody case update: Inquest to be listed”
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Lack of access to duty-lawyer immigration advice for deportable foreign national prisoners outside immigration detention centres
Wider context from the report “B. Foreign National Prisoners liable for deportation who are not in an Immigration Detention Centre currently have no access to a duty lawyer scheme . It is important that such subjects are not treated as favourably than those in an Immigration detention centre. This could be addressed by providing free legal advice on immigration matters from duty lawyers at a minimum via the prison estate pin phone system.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 senior Home Office manager for procedural liaison during inquests
Wider context from the report “D. In this inquest the Home Office were given the status of interested persons from an early stage. The Court has been greatly assisted by counsel and instructing solicitors acting for the department along with two witnesses. It was evident and unhelpful that the Home Office did not have a senior manager present throughout the proceedings to assist the court on procedures, if only by way of liaison . The inquest is not an immigration appeal tribunal and yet on evidence received it is more likely than not that Mr Netyks was exercising Treaty rights through employment and family life in North Wales. It appeared unfair that an incarcerated subject of the deportation process was required to provide evidence of the exercise of Treaty rights when the Home Office Caseworker could easily have made a check with the employer or HMRC for corroboration of his appeal against the stage one process. This is particularly concerning given English was a second language and all documentation was only provided in English. The facility to appear to speak and understand English is not the same as being able to comprehend the written word. This apparent unfairness could be addressed by the issue in B above, or by immigration officers explaining such documentation.
” Open source report
18 Dec 2018 John Anthony Delahaye · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 5 Failure to conduct a welfare check on cell unlock View source Failure to ensure healthcare attendance at ACCT reviews View source Unreliable recording of relevant past and current medical conditions View source Lack of clarity in the in possession medication risk assessment question View source Failure to use the in possession medication risk assessment View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
John Anthony Delahaye · 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
John Anthony Delahaye was found dead in his cell at HMP Birmingham on 5 March 2018 after taking an insulin overdose. The report identified concerns about the clarity and use of medication risk assessments, incomplete medical records, the absence of healthcare involvement in ACCT reviews, and the failure to carry out a welfare check when his cell was unlocked.
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 a welfare check on cell unlock
Wider context from the report “4. On the morning of the 5th March 2018 Mr. Delahaye’s cell had been unlocked at approximately 07:50. It is likely that he was already dead at this time (and had been so for some hours) but he was not found because the prison custody officer who unlocked his cell did not look into the cell or seek any kind of acknowledgement from Mr. Delahaye. It was acknowledged by the relevant PCO and by the Safer Custody Manager that unlock ought to have involved a welfare check. The Safer Custody Manager’s evidence is that the need for a welfare check on unlock has been emphasised to senior managers and leads through a bilateral document covered at formal briefings. However, it was not clear how this is then communicated down to the individual custody officers and how they are being audited to make sure they are conducting a welfare check on unlock. The absence of a welfare check creates a risk that a prisoner in need of life saving assistance at the time of unlock is not identified.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 healthcare attendance at ACCT reviews
Wider context from the report “3. No member of the healthcare team was present at any of Mr. Delahaye’s ACCT reviews. It was identified during the inquest that a member of either the mental health team, primary care or the drug/alcohol service ought to have been present at the first review at least. It was the evidence of a first line manager who had involvement in the ACCT that a member of the custodial team had contacted healthcare and asked them to attend but this was not documented and the healthcare team maintained they were unaware of the date of the first review. Whilst the ACCT book provides a checklist of actions to be undertaken at various times it does not include making healthcare aware of the first review. As this is a national Ministry of Justice form, HMP Birmingham can’t change it but a failure to inform healthcare of an ACCT review could result in useful knowledge or expertise not being available to the ACCT team and could put lives at risk.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Unreliable recording of relevant past and current medical conditions
Wider context from the report “2. During the inquest it emerged that the mental health nurse who assessed Mr. Delahaye on the 2nd January 2018 and the GP who assessed him for in possession medication on the 29th January 2018, had not identified from his notes all relevant past medical conditions. It emerged that whilst the System One records (a case management system used across the prison estate) has the facility to provide a summary of significant past and current medical conditions, it is not reliable at HMP Birmingham because conditions are not consistently given the correct ‘read code’ . Evidence from the NHS England clinical reviewer, ████████, was that this problem is not unique to HMP Birmingham and is found in other prison healthcare teams and requires a change of culture and practice to bring the system for read coding into line with that in the community. The absence of a reliable source for quickly identifying relevant past and current medical conditions puts lives at risk from misinformed decision making.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 clarity in the in possession medication risk assessment question
Wider context from the report “1. There is confusion surrounding the meaning of the following question from NHS England’s national clinical template for in possession Risk Assessments in the Secure Estate : “Have you had problems in the last 6 months with not taking, or not remembering to take your medicines as prescribed?” The Risk Assessment had not been used in the assessment for Mr. Delahaye’s in possession modification on the 29th January 2018 when it ought to have been. However, during the course of considering what the outcome would have been if the risk assessment had been undertaken, more than one clinician interpreted the question as pertaining only to consideration of incidents where medication had not been taken. It was the Coroner’s view that the question is also asking about incidents where medication may have been taken but not “as prescribed” thus encompassing an overdose (accidental or deliberate). The question is not clear and this creates a risk that the score generated may be incorrect and in possession medication may be authorised where it ought not to be, putting lives at risk.
2. During the inquest it emerged that the mental health nurse who assessed Mr. Delahaye on the 2nd January 2018 and the GP who assessed him for in possession medication on the 29th January 2018, had not identified from his notes all relevant past medical conditions. It emerged that whilst the System One records (a case management system used across the prison estate) has the facility to provide a summary of significant past and current medical conditions, it is not reliable at HMP Birmingham because conditions are not consistently given the correct ‘read code’. Evidence from the NHS England clinical reviewer, ████████, was that this problem is not unique to HMP Birmingham and is found in other prison healthcare teams and requires a change of culture and practice to bring the system for read coding into line with that in the community. The absence of a reliable source for quickly identifying relevant past and current medical conditions puts lives at risk from misinformed decision making.
3. No member of the healthcare team was present at any of Mr. Delahaye’s ACCT reviews. It was identified during the inquest that a member of either the mental health team, primary care or the drug/alcohol service ought to have been present at the first review at least. It was the evidence of a first line manager who had involvement in the ACCT that a member of the custodial team had contacted healthcare and asked them to attend but this was not documented and the healthcare team maintained they were unaware of the date of the first review. Whilst the ACCT book provides a checklist of actions to be undertaken at various times it does not include making healthcare aware of the first review. As this is a national Ministry of Justice form, HMP Birmingham can’t change it but a failure to inform healthcare of an ACCT review could result in useful knowledge or expertise not being available to the ACCT team and could put lives at risk.
4. On the morning of the 5th March 2018 Mr. Delahaye’s cell had been unlocked at approximately 07:50. It is likely that he was already dead at this time (and had been so for some hours) but he was not found because the prison custody officer who unlocked his cell did not look into the cell or seek any kind of acknowledgement from Mr. Delahaye. It was acknowledged by the relevant PCO and by the Safer Custody Manager that unlock ought to have involved a welfare check. The Safer Custody Manager’s evidence is that the need for a welfare check on unlock has been emphasised to senior managers and leads through a bilateral document covered at formal briefings. However, it was not clear how this is then communicated down to the individual custody officers and how they are being audited to make sure they are conducting a welfare check on unlock. The absence of a welfare check creates a risk that a prisoner in need of life saving assistance at the time of unlock is not identified.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 the in possession medication risk assessment
Wider context from the report “1. There is confusion surrounding the meaning of the following question from NHS England’s national clinical template for in possession Risk Assessments in the Secure Estate: “Have you had problems in the last 6 months with not taking, or not remembering to take your medicines as prescribed?” The Risk Assessment had not been used in the assessment for Mr. Delahaye’s in possession modification on the 29th January 2018 when it ought to have been. However, during the course of considering what the outcome would have been if the risk assessment had been undertaken, more than one clinician interpreted the question as pertaining only to consideration of incidents where medication had not been taken. It was the Coroner’s view that the question is also asking about incidents where medication may have been taken but not “as prescribed” thus encompassing an overdose (accidental or deliberate). The question is not clear and this creates a risk that the score generated may be incorrect and in possession medication may be authorised where it ought not to be, putting lives at risk.
2. During the inquest it emerged that the mental health nurse who assessed Mr. Delahaye on the 2nd January 2018 and the GP who assessed him for in possession medication on the 29th January 2018, had not identified from his notes all relevant past medical conditions. It emerged that whilst the System One records (a case management system used across the prison estate) has the facility to provide a summary of significant past and current medical conditions, it is not reliable at HMP Birmingham because conditions are not consistently given the correct ‘read code’. Evidence from the NHS England clinical reviewer, ████████, was that this problem is not unique to HMP Birmingham and is found in other prison healthcare teams and requires a change of culture and practice to bring the system for read coding into line with that in the community. The absence of a reliable source for quickly identifying relevant past and current medical conditions puts lives at risk from misinformed decision making.
3. No member of the healthcare team was present at any of Mr. Delahaye’s ACCT reviews. It was identified during the inquest that a member of either the mental health team, primary care or the drug/alcohol service ought to have been present at the first review at least. It was the evidence of a first line manager who had involvement in the ACCT that a member of the custodial team had contacted healthcare and asked them to attend but this was not documented and the healthcare team maintained they were unaware of the date of the first review. Whilst the ACCT book provides a checklist of actions to be undertaken at various times it does not include making healthcare aware of the first review. As this is a national Ministry of Justice form, HMP Birmingham can’t change it but a failure to inform healthcare of an ACCT review could result in useful knowledge or expertise not being available to the ACCT team and could put lives at risk.
4. On the morning of the 5th March 2018 Mr. Delahaye’s cell had been unlocked at approximately 07:50. It is likely that he was already dead at this time (and had been so for some hours) but he was not found because the prison custody officer who unlocked his cell did not look into the cell or seek any kind of acknowledgement from Mr. Delahaye. It was acknowledged by the relevant PCO and by the Safer Custody Manager that unlock ought to have involved a welfare check. The Safer Custody Manager’s evidence is that the need for a welfare check on unlock has been emphasised to senior managers and leads through a bilateral document covered at formal briefings. However, it was not clear how this is then communicated down to the individual custody officers and how they are being audited to make sure they are conducting a welfare check on unlock. The absence of a welfare check creates a risk that a prisoner in need of life saving assistance at the time of unlock is not identified.
” 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 Alert relevant staff daily to scheduled first ACCT reviews and quality-assure ACCT completion, required actions and healthcare attendance.
Verbatim wording from the response “In June 2018 all HMP Birmingham ACCT case managers and members of healthcare staff including those from the mental health team and integrated drug services, were reminded by way of a written staff briefing that they must attend all first ACCT case reviews, and any subsequent reviews where necessary. Since Mr Delahaye’s death, staff are now alerted at the Governing Governor’s daily staff meetings of the first ACCT case reviews which are scheduled for the day, and reminded of such by the communications room staff. In September 2018, the establishment set up a new quality assurance process by which members of the Safer Custody team check that all ACCT documents are completed in accordance with instructions and that all necessary actions have been taken.” Source location 2018-0388-Responses
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 a national learning bulletin reminding prison staff that ACCT reviews must be multidisciplinary, timely and supported by written contributions when attendance is impossible.
Verbatim wording from the response “In July 2018, HMPPS issued a Learning Bulletin (ACCT - Case Reviews, CAREMAPs and Levels of Conversations and Observations) to all prisons. The Bulletin reminded staff that ACCT review meetings must be multi-disciplinary and must take place within the specified timescales. It further stated that where any individual involved in the prisoner’s management cannot attend the review, they must submit written contributions.” Source location 2018-0388-Responses
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 Pilot an updated ACCT document and revised guidance requiring healthcare attendance at the first review and appropriate participation at subsequent reviews.
Verbatim wording from the response “Following a review of ACCT, we are currently in the process of piloting an updated ACCT document and revised guidance, which is clear that healthcare must attend the first case review, and is expected also to attend every subsequent review (and where this is not possible to provide a written contribution) in cases in which issues of physical or mental health have been identified as relevant. The pilot will run for a 4 month period from mid-February. It will be evaluated, and we hope to roll out the new procedure nationally in the autumn.” Source location 2018-0388-Responses
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 the Residential Activities, Basics and Cleanliness compliance process to support welfare checks during prisoner unlocks.
Verbatim wording from the response “Your second concern is that whilst you were told at the inquest that senior staff had been advised that unlocking prisoners should include a welfare check, it was not clear how this had been communicated to the staff who were actually unlocking prisoners, or how compliance would be monitored.” Source location 2018-0388-Responses
Open published response
30 Nov 2018 Mr Bradley Fraser Brown · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 3 Lack of national guidance on late prison transfers and cut-off points View source Failure to provide clinicians with access to transferring prisoners’ full healthcare records View source Inadequate weekend mental health staffing and risk assessment for late prison transfers 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
Mr Bradley Fraser Brown · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mr Bradley Fraser Brown was a serving prisoner who died in prison on 14 August 2017 after being found suspended by a ligature from a cell light fitting. The report identifies concerns about his late weekend transfer, limited access to healthcare records and assessments, reduced weekend healthcare provision, and the absence of national guidance on late prison transfers.
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 guidance on late prison transfers and cut-off points
Wider context from the report “1. Late transfer of Prisoners between Prisons - on Fridays/at a weekend puts Prisoners at increased risk of death as adequate mental health/risk assessments cannot be conducted. There are no mental health nurses available to assess/monitor prisoners over the weekend, thus making late transfers unsafe. The same concern applies, in principle, to public/bank holidays.
There are different levels of healthcare at the weekends as compared to weekdays. This gives cause for concern given the inherent susceptibilities with which prisoners frequently present.
Transfer itself creates vulnerability that requires additional support, intervention and care and is of particular concern where the transferring prisoner is being held in isolation within the Care and Separation Unit (CSU or ‘Seg’ as it is colloquially known).
By virtue of the very different prison regime at the weekends (increased lock up periods/isolation in cells, fewer staff on duty, reduced activities) timely risk assessment is critical in the prevention of self-harm leading to death.
Late transfer also risks inadequate assessment where the clinician concerned cannot access the prisoner’s full healthcare record, thus substantially reducing the amount of key information available to them. Where the transferring prisoner has not been seen by Healthcare, other clinicians such as mental health nurses cannot access the healthcare record database.
There is no national guidance in relation to late transfers/cut-off points etc.
2. Commissioning of Mental Health/Healthcare Services:
As commissioners for healthcare services within prisons, the above concerns are also being brought to the attention of NHS England, for action.
These issues are not unique to the Prison involved in Mr Brown’s case.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to provide clinicians with access to transferring prisoners’ full healthcare records
Wider context from the report “1. Late transfer of Prisoners between Prisons - on Fridays/at a weekend puts Prisoners at increased risk of death as adequate mental health/risk assessments cannot be conducted. There are no mental health nurses available to assess/monitor prisoners over the weekend, thus making late transfers unsafe. The same concern applies, in principle, to public/bank holidays.
There are different levels of healthcare at the weekends as compared to weekdays. This gives cause for concern given the inherent susceptibilities with which prisoners frequently present.
Transfer itself creates vulnerability that requires additional support, intervention and care and is of particular concern where the transferring prisoner is being held in isolation within the Care and Separation Unit (CSU or ‘Seg’ as it is colloquially known).
By virtue of the very different prison regime at the weekends (increased lock up periods/isolation in cells, fewer staff on duty, reduced activities) timely risk assessment is critical in the prevention of self-harm leading to death.
Late transfer also risks inadequate assessment where the clinician concerned cannot access the prisoner’s full healthcare record, thus substantially reducing the amount of key information available to them. Where the transferring prisoner has not been seen by Healthcare, other clinicians such as mental health nurses cannot access the healthcare record database.
There is no national guidance in relation to late transfers/cut-off points etc.
2. Commissioning of Mental Health/Healthcare Services:
As commissioners for healthcare services within prisons, the above concerns are also being brought to the attention of NHS England, for action.
These issues are not unique to the Prison involved in Mr Brown’s case.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Inadequate weekend mental health staffing and risk assessment for late prison transfers
Wider context from the report “1. Late transfer of Prisoners between Prisons - on Fridays/at a weekend puts Prisoners at increased risk of death as adequate mental health/risk assessments cannot be conducted . There are no mental health nurses available to assess/monitor prisoners over the weekend, thus making late transfers unsafe . The same concern applies, in principle, to public/bank holidays.
There are different levels of healthcare at the weekends as compared to weekdays . This gives cause for concern given the inherent susceptibilities with which prisoners frequently present.
Transfer itself creates vulnerability that requires additional support, intervention and care and is of particular concern where the transferring prisoner is being held in isolation within the Care and Separation Unit (CSU or ‘Seg’ as it is colloquially known).
By virtue of the very different prison regime at the weekends (increased lock up periods/isolation in cells, fewer staff on duty, reduced activities ) timely risk assessment is critical in the prevention of self-harm leading to death .
Late transfer also risks inadequate assessment where the clinician concerned cannot access the prisoner’s full healthcare record, thus substantially reducing the amount of key information available to them. Where the transferring prisoner has not been seen by Healthcare, other clinicians such as mental health nurses cannot access the healthcare record database.
There is no national guidance in relation to late transfers/cut-off points etc.
2. Commissioning of Mental Health/Healthcare Services:
As commissioners for healthcare services within prisons, the above concerns are also being brought to the attention of NHS England, for action.
These issues are not unique to the Prison involved in Mr Brown’s case.
” Open source report
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations