30 Nov 2018 Thomas Nicol · Prevention of Future Deaths report Hertfordshire
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Concerns raised 1 Delays in transferring prisoners in acute mental health crisis to suitable secure hospitals View source
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No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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Thomas Nicol · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Thomas Nicol, a serving prisoner at HMP The Mount, was found hanging in his cell on 21 September 2015 and died in hospital on 25 September 2015. The report raised concern that the weeks-to-months taken to transfer prisoners in acute mental health crisis to suitable secure hospitals potentially puts lives at risk.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Delays in transferring prisoners in acute mental health crisis to suitable secure hospitals
Wider context from the report “That the length of time taken to transfer prisoners in acute mental health crisis to a suitable secure hospital potentially puts lives at risk
” Open source report
16 Oct 2018 Jacqueline Oakes · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 1 Lack of a mechanism to alert other agencies when high-risk offenders are released after completing their full sentence View source
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Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Jacqueline Oakes · 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
Jacqueline Oakes was a vulnerable woman who suffered repeated assaults by a man she met in supported living accommodation. Her body was found in her flat on 14 January 2014, and the man was later convicted of her murder; the medical cause of death was multiple injuries. The principal concern was that no agencies were alerted when a high-risk offender was released after completing his sentence, limiting their ability to manage the risks he posed.
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 mechanism to alert other agencies when high-risk offenders are released after completing their full sentence
Wider context from the report “When an offender is released having completed their full sentence who is known to be a high risk to others there is no mechanism for any other agencies to be alerted to that person’s release . Had an alert been provided to other agencies that came into contact with Jacqueline and ████████ it would have meant they were better able to manage the risks he posed. Consideration should be given to whether such alerts can be provided.
” Open source report
Concerns raised 2 Failure to provide out-of-hours access to urgent Integrated Offender Manager communications View source Lack of post-release accommodation assistance View source
Responses linked to these concerns
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No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Thomas Philip Lear · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Thomas Philip Lear died by suicide on 6 January 2018 after he was found hanging from a fence post at his ex-partner’s property. The report raised concerns that no help with accommodation appeared to have been offered after his release from prison, and that urgent text messages reporting threats to hang himself were sent to an Integrated Offender Manager phone that was unavailable outside Monday to Friday without an apparent divert.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to provide out-of-hours access to urgent Integrated Offender Manager communications
Wider context from the report “(2) On Saturday 6th January 2018 he threatened to hang himself. At 3.37pm and at 5.03pm that day the mother of the deceased sent two text messages to the mobile phone of ████████is allocated Integrated Offender Manager (IOM) indicating that he had threatened to hang himself. The IOM phone number is only available Monday-Friday and there was no apparent divert to any other number which might have picked up the urgent nature of the text messages .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 post-release accommodation assistance
Wider context from the report “(1) The deceased had been released from prison on the 29th December 2018. He was homeless and lapsed quickly back into drug taking. An ex-partner offered him some temporary accommodation. On the 6th January she refused him admission to her house because he was clearly under the influence of drugs. Shortly after he hung himself in the rear garden at her address. It was not apparent at the inquest that any help had been offered to the deceased with regards to accommodation following his release from prison.
” Open source report
7 Sep 2018 Scott Patrick Carton · Prevention of Future Deaths report West Yorkshire Eastern
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Concerns raised 8 Lack of appropriate psychological input in release accommodation View source Failure to arrange immediate GP registration after release View source Failure to establish appropriate support services before release View source Failure to communicate a clear management plan to release-accommodation staff View source Failure to respond to relevant information about safe release placement View source Unavailability of appropriate psychological interventions in prison View source Insufficient psychological resource for prisoners released on licence View source Inadequate medical support in the release placement 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.
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AI-generated summary
Scott Patrick Carton · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Scott Patrick Carton was released from prison on 5 January 2017 to the Westgate Project Hostel in Wakefield and was found dead there on 10 January 2017. His death involved the synergistic combination of prescribed methadone, pregabalin and tramadol. Concerns included the suitability of his hostel placement, the lack of anticipated psychological support and a clear management plan, and wider gaps in support for prisoners with mental health and drug dependence issues before and after release.
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 appropriate psychological input in release accommodation
Wider context from the report “1. A probation report dated 18 July 2016 recommended Mr Carton’s release on licence, notwithstanding a failed release on licence in summer 2015, in which he swiftly reverted to illicit drugs. The 18 July 2016 report envisaged specialist psychological input at Approved Premises which had access to psychological resources and a ‘robust risk management plan in place’ In the event Mr Carton was sent to a different hostel which did not provide psychological inputs of the type envisaged, nor was any clear management plan communicated to the hostel staff who had to deal with Mr Carton's challenging behaviour. The likelihood of the hostel placement proving beneficial was thus compromised from the outset.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to arrange immediate GP registration after release
Wider context from the report “6. To maximise the prospect of a successful reintegration into society, prisoners with mental health issues and/or drug dependence need appropriate support services to be in place prior to their release and arrangements made to have them registered with a GP immediately (so as to provide a conduit to community mental health services)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to establish appropriate support services before release
Wider context from the report “6. To maximise the prospect of a successful reintegration into society, prisoners with mental health issues and/or drug dependence need appropriate support services to be in place prior to their release and arrangements made to have them registered with a GP immediately (so as to provide a conduit to community mental health services)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable 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 a clear management plan to release-accommodation staff
Wider context from the report “1. A probation report dated 18 July 2016 recommended Mr Carton’s release on licence, notwithstanding a failed release on licence in summer 2015, in which he swiftly reverted to illicit drugs. The 18 July 2016 report envisaged specialist psychological input at Approved Premises which had access to psychological resources and a ‘robust risk management plan in place’ In the event Mr Carton was sent to a different hostel which did not provide psychological inputs of the type envisaged, nor was any clear management plan communicated to the hostel staff who had to deal with Mr Carton's challenging behaviour. The likelihood of the hostel placement proving beneficial was thus compromised from the outset.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to respond to relevant information about safe release placement
Wider context from the report “2. The parents’ strenuous attempts to alert the Probation Service to the difficulties their son faced and the need for a placement at Approved Premises in a different area so as to avoid his drug connections, went unheeded .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 appropriate psychological interventions in prison
Wider context from the report “4. Having been diagnosed with an emotionally unstable personality disorder in 2013 Mr Carton needed to be allocated to a prison establishment which did provide appropriate psychological interventions. In the event he was placed in HMP Wealstun which did not provide such services . This diminished any prospect of him succeeding in the community when released.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 psychological resource for prisoners released on licence
Wider context from the report “5. Evidence taken at the inquest emphasised the paucity of psychological resource available to prisoners released on licence with emotionally unstable personality disorder and drug dependence issues . In consequence, individuals such as Mr Carton are released into the community when they are ill prepared. Unless adequate resources are available the result is likely to be that individuals will consume police and hospital resources as their condition deteriorates to the point where they are recalled to prison or their life ends in tragedy.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 medical support in the release placement
Wider context from the report “3. Evidence was taken from several witnesses who expressed views to the effect that the Westgate Project was not the appropriate place for Mr Carton as he needed ‘medical help’
” Open source report
27 Apr 2018 PAUL DAVID ANTHONY JAMES · Prevention of Future Deaths report Mid Kent and Medway
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Concerns raised 1 Failure to prevent access to razor blades View source
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AI-generated summary
PAUL DAVID ANTHONY JAMES · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
PAUL DAVID ANTHONY JAMES died in HMP Elmley on 20 December 2016 after inflicting an incised wound to his abdomen with a razor blade. The report identifies concern that he was given access to razor blades despite his history of serious self-harm and suicidal statements.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent access to razor blades
Wider context from the report “That Mr James was given access to razor blades in all the circumstances.
” Open source report
Concerns raised 4 Lack of formal training in reception duties View source Failure to inform staff of the manner of unnatural prisoner deaths View source Lack of written material informing reception officers of their duties View source Unavailability of breathing guards for senior officers during resuscitation View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Christopher Talbot · 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 Talbot, a prisoner at Preston Prison, was found with a plastic bag over his head after being identified as vulnerable and at risk of suicide. Resuscitation initially restored breathing and cardiac output, but he later died in hospital. Concerns included inadequate reception training, the absence of a breathing guard during resuscitation, insufficient sharing of information about similar deaths, and failures to request immediate assistance and maintain constant observation.
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 formal training in reception duties
Wider context from the report “(1) The Supervising Officer on duty at Reception when Mr Talbot arrived had never received training in her duties but merely gained experience by shadowing another officer . It did not appear that any written material was provided so as to inform her of her duties, including the PSI “Early Days In Custody, Reception In, First Night In Custody And Induction To Custody” or a guidance document summarising the main provisions of the PSI. Lack of such written material and reliance solely on shadowing as a means of training might bring about a position where bad habits are proliferated or important considerations 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 inform staff of the manner of unnatural prisoner deaths
Wider context from the report “(3) It is understood that following the death of a prisoner a notice to this effect is issued to the prisoners and staff but that staff are not informed of the manner of an unnatural death . Thus, it appeared that staff attending to give evidence at the inquest were unaware of another recent previous death involving a plastic bag , knowledge of which might have led to extra vigilance in the case of Mr Talbot, when as a vulnerable prisoner, he was observed holding a plastic bag.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Lack of written material informing reception officers of their duties
Wider context from the report “(1) The Supervising Officer on duty at Reception when Mr Talbot arrived had never received training in her duties but merely gained experience by shadowing another officer. It did not appear that any written material was provided so as to inform her of her duties , including the PSI “Early Days In Custody, Reception In, First Night In Custody And Induction To Custody” or a guidance document summarising the main provisions of the PSI. Lack of such written material and reliance solely on shadowing as a means of training might bring about a position where bad habits are proliferated or important considerations 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 Unavailability of breathing guards for senior officers during resuscitation
Wider context from the report “(2) A Senior Officer gave mouth to mouth resuscitation to Mr Talbot without the use of a guard. It is understood that although mandatory for more junior officers at HMP Preston, carrying a breathing guard at all times is discretionary for certain senior grades . Lack of such a guard might put an officer in personal danger when attempting to revive a prisoner or dissuade that officer from intervening , with potential adverse consequences for the prisoner.
” Open source report
28 Jul 2017 SARAH LYNNE REED · Prevention of Future Deaths report London (City)
View report summary
Concerns raised 17 Insufficient information provided to prisoner visitors View source Excessive cancellation of prisoner visits View source Failure of ACCT Review team members to fully review the ACCT document View source Failure to make recorded prisoner observations accessible to all relevant team members View source Failure to complete fitness-to-plead reports and fix a hearing date in a timely manner View source Failure to assign clear responsibility for obtaining fitness-to-plead reports View source Failure to facilitate prisoner visits despite behaviour-related barriers View source Failure to record prisoner observations immediately or as soon as practicable View source Failure to notify community care coordinators of prisoner release View source Failure to conduct ACCT reviews on a multidisciplinary basis View source Inappropriate reduction of observation frequency despite deteriorating mental state View source Failure to communicate the fitness-to-plead purpose of remand to the mental health team View source Delays in holding Care Programme Approach meetings View source Failure to require Duty Governor authorisation for cancelled visits View source Inadequate multidisciplinary participation in CPA meetings View source Inadequate quality and duration of CPA meetings View source Insufficient recording of cancelled visits View source See 14 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
SARAH LYNNE REED · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Sarah Lynne Reed took her own life on 11 January 2016 in a single-occupancy cell at HMP Holloway, using a ligature made from bed linen. The report identifies concerns about delays in obtaining fitness-to-plead reports, management of her medication and deteriorating mental health, inappropriate reduction of observations, delays and deficiencies in care planning, and cancelled visits that contributed to her isolation.
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 information provided to prisoner visitors
Wider context from the report “(18) The Coroner also observes that the information provided to visitors including close family was often short on detail and lacked helpful 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 Excessive cancellation of prisoner visits
Wider context from the report “(14) The jury concluded that the number of cancelled visits was unacceptable , particularly for a prisoner such as Sarah with Emotionally Unstable Personality Disorder where engagement is a principal means of treatment.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure of ACCT Review team members to fully review the ACCT document
Wider context from the report “(9) The jury also found that not all members of the ACCT Review team fully reviewed the ACCT document before making a decision .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable 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 recorded prisoner observations accessible to all relevant team members
Wider context from the report “(10) The jury also found the system of some members of the multi-disciplinary team recording observations which were not accessible to all other members of the team to be ‘detrimental’. For example, many helpful observations about Sarah’s behaviour were recorded in the prison medical notes on SystemOne by doctors and nurses, but they were not accessible to prison officers .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to complete fitness-to-plead reports and fix a hearing date in a timely manner
Wider context from the report “(1) The deceased had been remanded in custody for the sole purpose of the Court obtaining two reports by psychiatrists on her fitness to plead and stand trial. Yet by the time of her death, three months later, this objective had not been achieved and no date for a hearing of the issue had been fixed . It is clear from the evidence that Sarah was uncertain what was happening and when she would be going to 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 assign clear responsibility for obtaining fitness-to-plead reports
Wider context from the report “(4) It was not clear on the evidence who took responsibility for obtaining the reports . The Court had ordered them, but the formal request for the first report, dated 27 October 2015, was (a) directed to HMP Holloway, but (b) sent by email from the Court to an administrative officer employed not by the prison but by the Central and North West London NHS Trust (CNWL) who worked from HMP Holloway. One month later, on 27 November 2015, a psychiatrist employed by CNWL in HMP Holloway wrote back to the Court, apologising for the delay and indicating that the request be directed not to CNWL but to the South London and Maudsley NHS Trust. As a result, by about six weeks after the Court’s order, no psychiatrist had yet agreed to prepare a 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 facilitate prisoner visits despite behaviour-related barriers
Wider context from the report “(17) The Coroner also observes that with a little thought and effort arrangements could be made for a visit to Sarah even when her mental state had affected her behaviour . For example, on one occasion on 2 January 2016 (and apparently on one occasion only), Sarah’s mother was allowed to see Sarah in the adjudication room on the Segregation Unit (where Sarah was then housed). It is clear from the evidence that this visit was helpful to Sarah and that more completed visits would have assisted her . The jury so found.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to record prisoner observations immediately or as soon as practicable
Wider context from the report “(11) In addition the Coroner observes that HMP Holloway maintained a practice of recording observations on prisoners which deviated from the national instruction. According to the national policy Management of prisoners at risk of harm to self, to others and from others (Safer Custody) (PSI 64/2011) observations should be recorded ‘immediately or as soon as practicable thereafter’ . According to the local policy at HMP Holloway, as implemented in this case, any observations at any time need be recorded only at four hour intervals in summary form .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to notify community care coordinators of prisoner release
Wider context from the report “(19) There was evidence from Sarah’s care coordinator in the community, a social worker with the START Team, that she was never informed by HMP Holloway of the release of any prisoner whom she had previously supported in the community , despite the care coordinator having close links with the prison, for example visiting prisoners she had supported and sometimes taking part in CPA meetings. The care coordinator said that this would be ‘incredibly helpful’.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable 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 ACCT reviews on a multidisciplinary basis
Wider context from the report “(8) The jury also found that the above decision was not multi-disciplinary , which it should have been (as the senior Governor conceded in evidence).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Inappropriate reduction of observation frequency despite deteriorating mental state
Wider context from the report “(7) The jury concluded that the decision to reduce the frequency of observations on Sarah Reed at ACCT Review No.4 on 5 January 2016, six days before Sarah’s death, was inappropriate given the clear evidence of the deterioration of her mental state .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable 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 fitness-to-plead purpose of remand to the mental health team
Wider context from the report “(5) The jury found that the evidence that key members of Sarah’s mental health team in HMP Holloway were unaware that the sole purpose of her remand in custody was for the preparation of fitness to plead reports was ‘incomprehensible’.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Delays in holding Care Programme Approach meetings
Wider context from the report “(12) The jury concluded that the delay in holding a Care Programme Approach (CPA) meeting was unacceptable . The evidence showed that a CPA Meeting for assessing a prisoner’s long-term care should have been held within four weeks from reception . In this case it was held after nine weeks .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable 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 Duty Governor authorisation for cancelled visits
Wider context from the report “(16) The Governor conceded that the records for cancellations were insufficient and all cancellations should have been sanctioned at the level of Duty Governor (which they were not) and not by staff of lesser seniority.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 multidisciplinary participation in CPA meetings
Wider context from the report “(13) The jury also found that the quality of the meeting was not appropriate. It lasted five minutes and only the nurse care coordinator and community psychiatrist were present with the prisoner.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 quality and duration of CPA meetings
Wider context from the report “(13) The jury also found that the quality of the meeting was not appropriate . It lasted five minutes and only the nurse care coordinator and community psychiatrist were present with the prisoner.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 recording of cancelled visits
Wider context from the report “(16) The Governor conceded that the records for cancellations were insufficient and all cancellations should have been sanctioned at the level of Duty Governor (which they were not) and not by staff of lesser seniority.
” Open source report
21 Jun 2017 Michael Folley · Prevention of Future Deaths report Central Hampshire
View report summary
Concerns raised 13 Failure to complete SASH forms for risk information emerging outside current court detention View source Failure to ensure clarity about information available during prison reception View source Failure to ensure Detention Officer PER training is completed View source Failure to complete SASH forms for relevant recent self-harm or suicide risk View source Failure to ensure receipt and training for important medical and risk information at prison reception View source Cell safety features permitting door wedging and ligature use View source Radio connection delays affecting emergency information relay View source Failure to ensure secure handover of PER documentation View source Failure to provide PER staff with relevant previous self-harm and suicide risk information View source Failure of court custody staff to contribute relevant risk information to the PER View source Incomplete provision of anti-ligature protection on cell doors View source Failure to record checks of PER completion and quality View source Failure of regular maintenance checks to identify defective anti-barricade doors View source See 10 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Michael Folley · 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 Folley was remanded to HMP Winchester on 15 September 2017 and was found the following day suspended from a ligature made from torn bed sheets after barricading his cell door with mirrors and furniture. He was taken to hospital and died on 18 September 2017 after intensive care treatment. The principal concerns included the transfer and use of information about self-harm risk between police, court and prison; staff training; cell safety and maintenance; systems for checking barricaded cell doors; and the effectiveness of prison radios in relaying emergency calls.
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 complete SASH forms for risk information emerging outside current court detention
Wider context from the report “I was also left with a concern that GEOAmey staff would only complete a SASH form if the current risk was identified during Mr Folley’s detention at Portsmouth magistrates’ court and not if anything came to the attention of the court detention officer to indicate there was a risk of self-harm or suicide within the last month before arrest .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable 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 clarity about information available during prison reception
Wider context from the report “During the inquest, it became apparent that despite extensive questioning of police/custody staff, GEOAmey staff, prison officers and healthcare professionals, it would not be possible to establish with any degree of certainty exactly what information was available during the induction process once Mr Folley arrived at prison.
I heard from prison officers and a senior nurse involved in the reception process but there was no clarity regarding exactly what information was available to them namely, the PER itself, the HDLS reports or information that had clearly been faxed to the prison by court staff such as the warrants setting out the grounds for the remand.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure Detention Officer PER training is completed
Wider context from the report “c) Detention Officer PER training may not have been completed if a DO had many years of experience in the police force which would give what he referred to as “grandfather rights” .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable 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 SASH forms for relevant recent self-harm or suicide risk
Wider context from the report “h) The suicide/self harm warning alert (SASH) at page 9 of the PER was meant to be completed if there was a risk of self-harm or suicide since arrest or within the last month . In other words, it was felt the relevant period to be considered was not just the current period of detention but also anything relevant within a month before arrest. In this case the SASH form was never completed .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure receipt and training for important medical and risk information at prison reception
Wider context from the report “The nurse confirmed that at the time of Mr Folley’s reception checks he did not see the PER or HLDS reports but told me that he now does. In addition, he could not recall any specific training and the system for receipt of important medical information sounded haphazard as hardcopy documents were simply left on a desk .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Cell safety features permitting door wedging and ligature use
Wider context from the report “I heard evidence that prisoners are issued with plastic mirrors that are frequently used as wedges in cell doors . This means officers are vigilant to ensure prisoners only have one mirror each and if there are more in a cell than necessary they will be removed. It was suggested that a thicker mirror could be issued or a mirror/reflective panel could be inserted into the wall. This was an ongoing process of replacement in the prison.
Window design was also being considered and I was informed a trial had begun prison to roll out a new type of window but that this could take up to 2 years to complete .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Radio connection delays affecting emergency information relay
Wider context from the report “There was conflicting evidence during inquest about the effectiveness of when the Code Blue call was made and whether this resulted in any delay in the information being passed to the ambulance service. On balance of probabilities, the problem seemed to come from the fact that the custody manager did give the correct callsign but because there is a two second delay when pressing the radio button this may not have been picked up immediately in the control room . This is of significant concern both in respect of the safety prison officers but also the need to obtain medical help for prisoners and suggests the need to update the radio 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 Failure to ensure secure handover of PER documentation
Wider context from the report “e) The responsibility for the completion and quality of the PER rests with the releasing Custody Sergeant. When checking the detention log in the custody record in this case, there was no specific entry. This may not necessarily mean it was not checked by the custody sergeant but if it was then that action should be recorded.
f) It is the custody sergeant’s responsibility to ensure the safe transportation of a PER and associated documents by placing them in an envelope or other secure means that all documentation is safely handed over to the court custody officers .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to provide PER staff with relevant previous self-harm and suicide risk information
Wider context from the report “b) Mr Folley was assessed as NCTS (no current thoughts of self-harm or suicide) and thus placed on the lowest observation rate of 60 minutes. However, access to previous data held on police (both internal and external) and other agency systems was not available to officers completing the PER and thus they could rely on current observations only . Despite this, it was essential to consider the risk of self-harm or suicide demonstrated and recorded over the previous months (July – September) not simply since detention on this occasion.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable 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 court custody staff to contribute relevant risk information to the PER
Wider context from the report “I am concerned that the impression created was that GEOAmey staff do not actively engage in and contribute to the contents of the PER to highlight any information relevant to risk assessment irrespective of what source it comes from.
In addition, there was apparently no log of ████████ call to the court cells. The electronic PER had been checked and nothing was logged. There is no reason to believe ████████ call was not made and it is of concern that there was no apparent system for logging such a call let alone action in the contents of her request .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 provision of anti-ligature protection on cell doors
Wider context from the report “I also heard that steps had been taken to fit anti-ligature strips in some but not all cell doors .
All of these suggestions seemed eminently sensible yet the pace of these changes does need to be considered .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to record checks of PER completion and quality
Wider context from the report “e) The responsibility for the completion and quality of the PER rests with the releasing Custody Sergeant. When checking the detention log in the custody record in this case, there was no specific entry . This may not necessarily mean it was not checked by the custody sergeant but if it was then that action should be recorded .
f) It is the custody sergeant’s responsibility to ensure the safe transportation of a PER and associated documents by placing them in an envelope or other secure means that all documentation is safely handed over to the court custody officers.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure of regular maintenance checks to identify defective anti-barricade doors
Wider context from the report “I heard evidence that every effort was made to gain quick access into Mr Folley self once it became apparent that he had barricaded the door. This was significantly hindered by painting the screws on the anti-barricade plate but significantly, by the fact that even when the plate was removed the bar would not open outwards towards this landing due to a brick hanging down in the door frame. Whilst it has to be accepted that Winchester prison is not a modern prison nevertheless this should have been picked up during regular maintenance checks . I was shown some records this tended to imply that either checks had not been carried out on a regular basis or the checks themselves were not adequate . Either way this is of concern.
” Open source report
27 Nov 2016 Matthew RUSSELL · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 11 Failure to ensure multidisciplinary ACCT Case Reviews with relevant medical-practitioner participation View source Inadequate foundation and ongoing ACCT-procedure training for staff responsible for patients in prison View source Failure to properly and regularly monitor repeat-prescription medication View source Lack of structured care plans for each patient View source Ineffective communication about patients’ needs with GPs and primary healthcare practitioners at HMP High Down View source Failure of Gate House staff to understand the proper procedure for safety or wellbeing concern calls View source Failure to effectively use Read Codes to flag significant patient-care risk factors View source Failure to effectively follow up patients who miss pre-booked clinical appointments View source Failure of caseworkers to be aware of and attend ACCT Case Reviews View source Failure to conduct risk assessments for individual prisoners View source Inadequate foundation and ongoing ACCT-procedure training for staff 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
Matthew RUSSELL · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Matthew Russell was a serving prisoner who was found hanging by a ligature from his cell door and died in hospital the following day. The jury concluded that multiple failures in the management and application of the ACCT plan procedure materially contributed to his death, including concerns about medication monitoring, care planning, multidisciplinary reviews, staff training, risk assessment and communication.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure multidisciplinary ACCT Case Reviews with relevant medical-practitioner participation
Wider context from the report “HM Prison High Down
a. Ensuring that all staff have received adequate foundation and on-going training in the ACCT procedure, with particular emphasis on:
• Requiring ACCT Case Reviews to be multidisciplinary and thereby ensuring that all relevant medical practitioners are aware of the date and time of any such review and have been invited to attend .
• Risk Assessments in relation to individual 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 Inadequate foundation and ongoing ACCT-procedure training for staff responsible for patients in prison
Wider context from the report “e. Ensuring that all staff with responsibility for patients in prison have received adequate foundation training and on-going training in the ACCT procedure .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to properly and regularly monitor repeat-prescription medication
Wider context from the report “Central and North West London Foundation Trust
a. The proper and regular monitoring of all medication that is prescribed by way of a repeat prescription .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Lack of structured care plans for each patient
Wider context from the report “b. The preparation of structured care plans for each patient .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Ineffective communication about patients’ needs with GPs and primary healthcare practitioners at HMP High Down
Wider context from the report “g. Ensuring that there is regular effective communication about a patient’s needs with the GPs and the primary healthcare practitioners at HMP High Down .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable 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 Gate House staff to understand the proper procedure for safety or wellbeing concern calls
Wider context from the report “b. Ensuring that all Gate House staff understand the proper procedure to adopt when receiving a call from a prisoner's family or friends expressing concerns for that prisoner’s safety or wellbeing .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable 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 use Read Codes to flag significant patient-care risk factors
Wider context from the report “d. The effective use of Read Codes on the System One record, to flag up and highlight significant risk factors in a patient’s 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 effectively follow up patients who miss pre-booked clinical appointments
Wider context from the report “c. An effective procedure for following up patients who fail to attend pre-booked appointments with clinicians .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure of caseworkers to be aware of and attend ACCT Case Reviews
Wider context from the report “f. Ensuring that caseworkers are aware of and attend ACCT Case Reviews for patients under their 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 conduct risk assessments for individual prisoners
Wider context from the report “HM Prison High Down
a. Ensuring that all staff have received adequate foundation and on-going training in the ACCT procedure, with particular emphasis on:
• Requiring ACCT Case Reviews to be multidisciplinary and thereby ensuring that all relevant medical practitioners are aware of the date and time of any such review and have been invited to attend.
• Risk Assessments in relation to individual 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 Inadequate foundation and ongoing ACCT-procedure training for staff
Wider context from the report “HM Prison High Down
a. Ensuring that all staff have received adequate foundation and on-going training in the ACCT procedure , with particular emphasis on:
• Requiring ACCT Case Reviews to be multidisciplinary and thereby ensuring that all relevant medical practitioners are aware of the date and time of any such review and have been invited to attend.
• Risk Assessments in relation to individual prisoners.
” Open source report
8 Nov 2016 Ms Michelle Ann Lawrence · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 6 Insufficient CCTV-monitoring facilities for detainees at risk in custody View source Insufficient PNC character capacity for meaningful risk recording View source Lack of independent investigation into deaths following release from private custody providers View source Failure to ask detainees about concealment View source Unavailability of strip-search facilities in SERCO custody View source Failure to routinely check toilets for concealed items after detainee use 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
Ms Michelle Ann Lawrence · 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
Ms Michelle Ann Lawrence died at home on 2 May 2015 from respiratory failure after taking multiple prescription and illegal sedative drugs, following periods in police and private custody. The principal concerns included failures to identify concealed drugs, limited strip-searching and CCTV facilities, inadequate checking of custody-suite toilets, insufficient detail in risk records, and the lack of independent investigation into deaths following release from private custody providers.
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 CCTV-monitoring facilities for detainees at risk in custody
Wider context from the report “(5) That all custody suites have sufficient facilities for CCTV monitoring of detainees at risk in custody whether held by the State or private custody providers.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 PNC character capacity for meaningful risk recording
Wider context from the report “(6) That the number of characters on the PNC where risks are described and highlighted need to be increased to allow sufficient meaningful detail to be recorded to allow accurate risk assessment by staff without having to trawl through multiple electronic documents .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Lack of independent investigation into deaths following release from private custody providers
Wider context from the report “(1) That there is no independent investigation into the deaths of persons following release from private providers of custody analogous to the IPCC such that important evidence is lost that upon analysis may be used to learn lessons and thus 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 Failure to ask detainees about concealment
Wider context from the report “(2) That detainees are currently not asked about concealment . Such questions at booking in by police and on transfer between custody providers and when in consultation with health care professionals would provide an opportunity for some individuals who conceal to be identified either by positive responses to such questions or by allowing staff to assess their credibility. Ms Lawrence had admitted to taking drugs whilst in custody in February 2015.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 strip-search facilities in SERCO custody
Wider context from the report “(3) That facilities for strip searching appear to be virtually non-existent for those in the custody of SERCO.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable 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 routinely check toilets for concealed items after detainee use
Wider context from the report “(4) That SERCO staff do not appear to routinely check toilets for concealed items after they have been used by detainees .
” Open source report
25 Oct 2016 Richard Walsh · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 6 Failure to consider the whole person and reconcile or communicate missing and discordant information during proforma completion View source Failure of detained organisations to pass risk information consistently between one another View source Inadequate nurse assessment of fitness for segregation View source Lack of an agreed system for transferring health care information from police stations or courts to prisons View source Inadequate standard of Mental Health Act assessments View source Lack of clear responsibility for passing or seeking relevant information 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
Richard Walsh · 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
Richard Walsh was detained after being charged with attempted murder and, while experiencing delusions, refused food and drink with the stated intention of dying. He was transferred between HMP Highdown and HMP Belmarsh, where he was isolated in a single cell for 23½ hours a day and later died by hanging. The principal concerns were failures in communication and information-sharing between police, mental health, court and prison services, inadequate mental health assessment, and inadequate assessment of his fitness for segregation and suicide risk.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to consider the whole person and reconcile or communicate missing and discordant information during proforma completion
Wider context from the report “There appeared to be a focus by individuals on completing the proforma or questionnaire required by the system, by rote with either no time to consider the whole person , or no sense that it was their responsibility to consider missing or discordant information or to be proactive in communicating gaps in knowledge or concerns . From the evidence of a number of witnesses, the pattern of communication was not exceptional in this instance but reflected what usually happened.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable 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 detained organisations to pass risk information consistently between one another
Wider context from the report “There was no agreed system for transfer of health care information from police station or court, or from either to prison. There was no functioning and consistent system of passing risk information from one detained organization to another. There was not agreement whether there just was a duty to pass the information or if it was not in possession, whether there was also one to ask for it and if so which individual bore that responsibility.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 nurse assessment of fitness for segregation
Wider context from the report “3. That the inadequacy of the nurse assessment of fitness for segregation in HMP Highdown (see m) above) is a risk. ████████ was not ACCT trained and it appeared that he was unaware of PSI 1700. The inadequacy may reflect individual or wider weaknesses in assessment or choice of assessors that mean that prisoners go to segregation when they should be in the health care wing, or that they go without observation, when they should be on an ACCT and receive extra support.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 agreed system for transferring health care information from police stations or courts to prisons
Wider context from the report “There was no agreed system for transfer of health care information from police station or court, or from either to prison. There was no functioning and consistent system of passing risk information from one detained organization to another. There was not agreement whether there just was a duty to pass the information or if it was not in possession, whether there was also one to ask for it and if so which individual bore that responsibility.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 standard of Mental Health Act assessments
Wider context from the report “2. That the standard of Mental Health Act assessments by these individuals needs to be improved , and, given all three were in complete agreement, that also training and provision for MHA assessments in police stations more widely may need to be reviewed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 responsibility for passing or seeking relevant information
Wider context from the report “There was no agreed system for transfer of health care information from police station or court, or from either to prison. There was no functioning and consistent system of passing risk information from one detained organization to another. There was not agreement whether there just was a duty to pass the information or if it was not in possession, whether there was also one to ask for it and if so which individual bore that responsibility.
” Open source report
25 Oct 2016 Ivy Atkin · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 2 Lack of reliable independent and objective assessment of Nominated Individual suitability View source Failure to obtain and consider DBS certificates for proposed Nominated Individuals 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
Ivy Atkin · 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
Ivy Atkin was a resident at Autumn Grange Residential Care Home and died as a result of gross neglect. The Provider and its Nominated Individual were convicted of offences arising directly from her death, and an inquest recorded a conclusion of unlawful killing. Concerns included the Nominated Individual’s failure to provide a DBS certificate and a regulatory loophole affecting the independent assessment of suitability for that role.
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 reliable independent and objective assessment of Nominated Individual suitability
Wider context from the report “1. ████████ had criminal convictions including for an offence involving violence against another person. He had not provided a Disclosure and Barring Service (“DBS”) certificate to the CQC nor been asked to do so, before becoming Nominated Individual.
2. The CQC were therefore unable to assess whether or not ████████ was of good character and was suitable for the position of Nominated Individual, that person being responsible for the supervising the management of a Residential Care Home, a role which ████████ undertook.
3. This is because the CQC expected and still expects a Provider to consider DBS certificates and make decisions as to the suitability of a proposed Nominated Individual, where the Provider is (as was here) a limited company.
4. In the case of a small family owned limited company, where the controlling director and Nominated Individual are one and the same person, as in this case, there is therefore no reliable nor independent nor objective means of assessing the good character, safety and suitability of a Nominated Individual.
5. This is because the wording of the present Regulation 6 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 allows for such a “loophole”, and/or in the alternative the manner in which the CQC interprets its powers and duties in the light of this Regulation allows for such a loophole.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable 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 and consider DBS certificates for proposed Nominated Individuals
Wider context from the report “1. ████████ had criminal convictions including for an offence involving violence against another person. He had not provided a Disclosure and Barring Service (“DBS”) certificate to the CQC nor been asked to do so, before becoming Nominated Individual.
2. The CQC were therefore unable to assess whether or not ████████ was of good character and was suitable for the position of Nominated Individual, that person being responsible for the supervising the management of a Residential Care Home, a role which ████████ undertook.
3. This is because the CQC expected and still expects a Provider to consider DBS certificates and make decisions as to the suitability of a proposed Nominated Individual , where the Provider is (as was here) a limited company.
4. In the case of a small family owned limited company, where the controlling director and Nominated Individual are one and the same person, as in this case, there is therefore no reliable nor independent nor objective means of assessing the good character, safety and suitability of a Nominated Individual.
5. This is because the wording of the present Regulation 6 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 allows for such a “loophole”, and/or in the alternative the manner in which the CQC interprets its powers and duties in the light of this Regulation allows for such a loophole.
” Open source report
Concerns raised 6 Premature closure of ACCTs before identified inadequacies are detected and needs are properly served View source Failure of the ACCT document to accompany prisoners around the prison View source Failure to read and use available documentary information in ACCT reviews View source Insufficient resourcing for officers’ duties to keep prisoners safe from self-harm View source Failure to complete ACCT documentation fully View source Failure to invite all appropriate individuals to ACCT reviews View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Liam Adrian John Lambert · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Liam Adrian John Lambert was a young offender at Glen Parva Young Offenders Institution who died after ligaturing himself in a single cell on the evening of 19 March 2015. The report identified concerns about bullying and assaults, inadequate completion and use of the ACCT self-harm documentation, its inappropriate closure, prison resourcing, and delays in the emergency response and access for paramedics.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Premature closure of ACCTs before identified inadequacies are detected and needs are properly served
Wider context from the report “2. This ACCT was only open for a short period. It did not serve Liam’s needs properly and was closed before any review system picked up the inadequacies.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure of the ACCT document to accompany prisoners around the prison
Wider context from the report “1. The ACCT document was not completed fully, did not accompany Liam around the prison as it should have and not all appropriate individuals were invited to the reviews. Available documentary information was not read or used, and pressures of time were cited to explain these failings. Consideration should be given to formally confirming that all necessary documentation has been considered prior to the ACCT review, and to ensure the Officers and Healthcare staff are aware of their responsibilities.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable 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 read and use available documentary information in ACCT reviews
Wider context from the report “1. The ACCT document was not completed fully, did not accompany Liam around the prison as it should have and not all appropriate individuals were invited to the reviews. Available documentary information was not read or used , and pressures of time were cited to explain these failings. Consideration should be given to formally confirming that all necessary documentation has been considered prior to the ACCT review, and to ensure the Officers and Healthcare staff are aware of their responsibilities.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 resourcing for officers’ duties to keep prisoners safe from self-harm
Wider context from the report “3. The Governor provided evidence that resourcing was affecting the ability of officers to carry out their duties regarding keeping prisoners safe from self harm . In this particularly vulnerable population of young men, their safety is paramount and this should be the first consideration.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable 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 ACCT documentation fully
Wider context from the report “1. The ACCT document was not completed fully , did not accompany Liam around the prison as it should have and not all appropriate individuals were invited to the reviews. Available documentary information was not read or used, and pressures of time were cited to explain these failings. Consideration should be given to formally confirming that all necessary documentation has been considered prior to the ACCT review, and to ensure the Officers and Healthcare staff are aware of their responsibilities.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to invite all appropriate individuals to ACCT reviews
Wider context from the report “1. The ACCT document was not completed fully, did not accompany Liam around the prison as it should have and not all appropriate individuals were invited to the reviews . Available documentary information was not read or used, and pressures of time were cited to explain these failings. Consideration should be given to formally confirming that all necessary documentation has been considered prior to the ACCT review, and to ensure the Officers and Healthcare staff are aware of their responsibilities.
” 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 Implement national review recommendations, including revisions to ACCT policy and forms.
Verbatim wording from the response “The two matters of concern that you have raised about the operation of the ACCT process in this case are reflected in the outcome of a national review undertaken in 2015, which found that the policy and system are sound, but that work is needed on improving compliance with policy and the quality of delivery of care. The review made 20 recommendations, including revision to the policy and to the form, and these are currently being addressed. We aim to complete implementation by March 2017, and will continue to monitor the performance of the ACCT system to ensure that the anticipated improvements are delivered.” Source location 2016-0335-Response-by-NOMS
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 Conduct regular management checks and quality assurance of ACCT documentation and procedures.
Verbatim wording from the response “In September 2016 all staff were reminded at staff briefings of the need for all ACCT documents to be completed fully, and that they should record all relevant information in the ACCT document, and in the wing observation book and on P-NOMIS where appropriate. Staff were also reminded that ACCT documents must accompany prisoners when they move around the prison. Management checks are now regularly undertaken to ensure that staff are correctly completing the documents, and all ACCT documents are quality assured and monitored by the Head of Safer Custody.” Source location 2016-0335-Response-by-NOMS
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use a local ACCT review template requiring confirmation that relevant documentation has been read before reviews.
Verbatim wording from the response “A notice has been issued to remind staff of their responsibilities when attending ACCT case reviews, and a local template for reviews was introduced in October 2016. This prompts case managers to check that all relevant documentation is available and requires them to confirm that they have read it before undertaking the review. A new scheduling system was also introduced in October 2016, and this will ensure that sufficient time is allocated to all future case review meetings.” Source location 2016-0335-Response-by-NOMS
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue monitoring ACCT system performance to assess delivery of anticipated improvements.
Verbatim wording from the response “The two matters of concern that you have raised about the operation of the ACCT process in this case are reflected in the outcome of a national review undertaken in 2015, which found that the policy and system are sound, but that work is needed on improving compliance with policy and the quality of delivery of care. The review made 20 recommendations, including revision to the policy and to the form, and these are currently being addressed. We aim to complete implementation by March 2017, and will continue to monitor the performance of the ACCT system to ensure that the anticipated improvements are delivered.” Source location 2016-0335-Response-by-NOMS
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 Remind staff to complete ACCT documents fully, record relevant information, and move documents with prisoners.
Verbatim wording from the response “In September 2016 all staff were reminded at staff briefings of the need for all ACCT documents to be completed fully, and that they should record all relevant information in the ACCT document, and in the wing observation book and on P-NOMIS where appropriate. Staff were also reminded that ACCT documents must accompany prisoners when they move around the prison. Management checks are now regularly undertaken to ensure that staff are correctly completing the documents, and all ACCT documents are quality assured and monitored by the Head of Safer Custody.” Source location 2016-0335-Response-by-NOMS
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consider increasing Glen Parva’s benchmark operating level by 12 prison officers through the submitted business case.
Verbatim wording from the response “Staffing levels in public sector prisons have been set through a benchmarking process, designed to provide sufficient staff for the prison to operate safely, decently and securely. The Governor has raised concerns about the staffing level at Glen Parva, and recently submitted a business case to increase by 12 prison officers the benchmark operating level set for the prison. This is under consideration. Moreover, the prison has frequently been operating below this level, as there are currently a number of staff vacancies, most significantly at prison officer and operational support grade levels, and these are having an impact on the regime. Where there are insufficient staff available to deliver the new benchmarked regime, proportionate curtailments to the regime are made.” Source location 2016-0335-Response-by-NOMS
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use the Safer Custody toolkit to provide local ACCT procedures aligned with national policy.
Verbatim wording from the response “You will be aware that Prison Service Instruction 64/2011 Safer Custody sets out the relevant policy, and that chapter 5 describes the processes associated, Assessment, Care in Custody and Teamwork (ACCT) document. A Safer Custody toolkit was introduced at Glen Parva in August 2016, providing clear local instructions that are in accordance with the national policy.” Source location 2016-0335-Response-by-NOMS
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 Employ over 400 additional prison officers in ten particularly challenging prisons by March 2017 to provide dedicated regular one-to-one support.
Verbatim wording from the response “In the light of the evidence of increased violence and higher levels of self-inflicted deaths in prisons, the Secretary of State for Justice recently announced that an additional 2,500 more prison officers will be employed across the prison estate by the end of 2018. This includes an immediate investment of £14m to bring over 400 additional prison officers into ten particularly challenging prisons by March 2017. This will allow every offender to have a dedicated prison officer offering regular, one-to-one support.” Source location 2016-0335-Response-by-NOMS
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 Remind ACCT case managers to use multidisciplinary reviews, address prisoners’ needs in care maps, and complete actions before closure.
Verbatim wording from the response “In September 2016 ACCT case managers were reminded of the importance of a multi-disciplinary approach to ACCT reviews, particularly when making decisions to close the document. They were also reminded to check that the ACCT care map addresses the prisoner’s needs and that all the actions must be completed satisfactorily before the ACCT document is closed. Management checks are now regularly undertaken to ensure that staff correctly follow these procedures, and all ACCT documents are quality assured and monitored by the Head of Safer Custody. The Governor is confident that the new system of more consistent management checks, introduced in July 2016, has significantly improved the implementation of the ACCT process at the prison.” Source location 2016-0335-Response-by-NOMS
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The national ACCT policy and system are sound; the identified problems concern compliance with policy and quality of care delivery.
Verbatim wording from the response “The two matters of concern that you have raised about the operation of the ACCT process in this case are reflected in the outcome of a national review undertaken in 2015, which found that the policy and system are sound, but that work is needed on improving compliance with policy and the quality of delivery of care. The review made 20 recommendations, including revision to the policy and to the form, and these are currently being addressed. We aim to complete implementation by March 2017, and will continue to monitor the performance of the ACCT system to ensure that the anticipated improvements are delivered.” Source location 2016-0335-Response-by-NOMS
Open published response
12 Aug 2016 Stephen St Clair · Prevention of Future Deaths report Isle of Wight
View report summary
Concerns raised 3 Failure of suicide risk guidance to include irrational behaviour indicative of psychosis View source Failure to open an ACCT document when behaviour indicates a need for additional monitoring View source Lack of descriptions of symptoms of undiagnosed mental illness in suicide risk guidance View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Stephen St Clair · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Stephen St Clair, a prisoner at HMP Isle of Wight, was found in his cell on 4 November 2013 with a severe cut to his throat and was pronounced dead at 05.55 hours. The report describes concerns about signs of paranoia and possible psychosis not being recognised as suicide or self-harm risk, and about the absence of corresponding wording in the Prison Service suicide risk guidance, which may have contributed to an ACCT not being opened.
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 suicide risk guidance to include irrational behaviour indicative of psychosis
Wider context from the report “2. The next section in PSI 64/2011 deals with “Risk Factors for Self-Harm” and includes a sub-heading entitled “Current Context” where the following is included: “Irrational behaviour, out of touch with reality”.
3. I am concerned that the “Risk Factors for Suicide” does not actually include words to the effect of “Irrational behaviour, out of touch with reality” as the evidence from the Consultant Forensic Psychiatrist suggested that this behaviour was strongly suggestive of psychosis , and as such, the prisoner was in need of additional monitoring to keep him safe and to protect him from self-harm or suicide.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to open an ACCT document when behaviour indicates a need for additional monitoring
Wider context from the report “4. I am concerned that as this additional wording was not included in PSI 64/2011, the Prison Officers did not feel obligated to open an ACCT document , which may have resulted in Mr St Clair being monitored more closely, thereby avoiding him taking his own life.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 descriptions of symptoms of undiagnosed mental illness in suicide risk guidance
Wider context from the report “1. The Prison Service Instruction (“PSI”) 64/2011 (Management of prisoners at risk of harm to self, to others and from others (Safer Custody)) addresses the “Risk Factors for Suicide”. There are various subheadings, including “Clinical History” where the following point is made: “Mental illness diagnosis (e.g. depression, bipolar disorder, schizophrenia)” but there is no description of the possible symptoms which might be displayed by those who may be suffering from as yet undiagnosed conditions .
” Open source report
6 Jun 2016 STEVEN MARK TRUDGILL · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 1 Unavailability of standardised treatment programmes for fire setters within HM Prison Service 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
STEVEN MARK TRUDGILL · 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
Steven Trudgill was found hanging in his cell at HMP Highpoint on 9 January 2014 while on an open ACCT document. The report described a longstanding and complex mental health history, the absence of standardised treatment programmes for fire setters within HM Prison Service, and a suggested Therapeutic Community option that was not taken forward before his death. The inquest jury concluded that his death was suicide.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Unavailability of standardised treatment programmes for fire setters within HM Prison Service
Wider context from the report “He was clearly a young man with some insight and some complex mental health issues, and the trifesetting offences and behaviour, longstanding in his case, for which he had been convicted was a form of behaviour, according to the forensic psychologists’ report, that could, in some cases, have a significant underlying psychological component. The same detailed psychological report also identified five main factors which had been recognised to underlie deliberate fire setting behaviour, and found they could all be related to Steven’s own history. It was also stated that there are currently no standardised treatment programmes for fire setters available within HM Prison Service , and a pilot that had been running was no longer accepting referrals .
” Open source report
Concerns raised 3 Lack of healthcare staff experience and knowledge for recognising malaria and tropical diseases View source Lack of healthcare staff experience and knowledge for recognising malaria and tropical diseases View source Failure to ensure transfer of medical records from previous custodial establishments 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
Adetokunbo Ohisaga Ajakaiye · 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
Adetokunbo Ohisaga Ajakaiye was arrested on 13 November 2010, transferred to HMP Doncaster, and later taken to hospital, where he died of malaria early on 25 November 2010. Concerns included healthcare staff’s lack of practical experience and knowledge concerning malaria and tropical diseases, and the failure of medical records from earlier custodial establishments to accompany him to HMP Doncaster.
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 healthcare staff experience and knowledge for recognising malaria and tropical diseases
Wider context from the report “2. It became apparent, from the evidence, that none of the healthcare staff who dealt with Mr Ajakaiye at HMP Doncaster, had, prior to November 2010, any practical experience of dealing with a patient suffering from malaria and that there was a lack of knowledge and understanding of the signs and symptoms of malaria and of tropical diseases generally in circumstances where, in an era of increased foreign travel and inward migration, the incidence of malaria is likely to increase.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Lack of healthcare staff experience and knowledge for recognising malaria and tropical diseases
Wider context from the report “1. It became apparent, from the evidence, that none of the healthcare staff who dealt with Mr Ajakaiye at HMP Doncaster, had, prior to November 2010, any practical experience of dealing with a patient suffering from malaria and that there was a lack of knowledge and understanding of the signs and symptoms of malaria and of tropical diseases generally in circumstances where, in an era of increased foreign travel and inward migration, the incidence of malaria is likely to increase.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure transfer of medical records from previous custodial establishments
Wider context from the report “1. When Mr Ajakaiye arrived at HMP Doncaster on 15th November 2010 it appears that his medical records from Heathrow Airport Police Station and Lawcroft House Police Station did not accompany him . The doctor who saw Mr Ajakaiye, on 16th November 2010, stated, in her evidence, that it would have assisted her in her diagnosis had she had those medical records available to her at that appointment. The court heard that, whilst the medical records from previous custodial establishments sometimes accompanied the Prisoner Escort Records, it was not infrequently the case that they did not .
” Open source report
26 May 2016 Ian Keith Brown · Prevention of Future Deaths report Milton Keynes
View report summary
Concerns raised 3 Rising numbers of suicides and self-harm deaths in the prison View source Failure to maintain adequate ACCT case management documentation View source Failure to implement previous safety recommendations View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Ian Keith 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
Ian Keith Brown, who had mental illness and was on remand at HMP Woodhill, was found in his cell with a belt ligature around his neck on 19 July 2015 and was pronounced dead at 14:00 hours. Concerns were raised that recommendations to improve suicide and self-harm prevention, including ACCT case management and a prison-wide strategy, had not been implemented sufficiently, while suicides and self-harm at HMP Woodhill continued to rise.
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 Rising numbers of suicides and self-harm deaths in the prison
Wider context from the report “(1)During the course of the evidence I was referred to the most recent report from the HM Inspector of Prisons that highlighted “Recommendations made by the Prisons and Probation Ombudsman following previous deaths in custody, such as the need to improve the quality of ACCT case management documentation for prisoners at risk of suicide or self harm, had not been implemented with sufficient rigour.
(2) Deaths at the prison from suicide and self harm continue to rise.
(3) The recommendation from the Inspectors is that there should be a “prison-wide strategy and action plan to reduce the number of self inflicted deaths and incidents of self harm should be developed urgently. This should be based on detailed data and trend analysis and include implementation of Prison and Probation Ombudsman recommendations. It should also include improvements in the quality of ACCT case management documentation, and the lessons learned from internal investigations into life-threatening incidents.” I have concerns that the recommendations will not be implemented and that past recommendations have been ignored.
(4) That despite my previous PFD reports the number of suicides at HMP Woodhill continue to rise.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable 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 ACCT case management documentation
Wider context from the report “(1)During the course of the evidence I was referred to the most recent report from the HM Inspector of Prisons that highlighted “Recommendations made by the Prisons and Probation Ombudsman following previous deaths in custody, such as the need to improve the quality of ACCT case management documentation for prisoners at risk of suicide or self harm , had not been implemented with sufficient rigour .
(2) Deaths at the prison from suicide and self harm continue to rise.
(3) The recommendation from the Inspectors is that there should be a “prison-wide strategy and action plan to reduce the number of self inflicted deaths and incidents of self harm should be developed urgently. This should be based on detailed data and trend analysis and include implementation of Prison and Probation Ombudsman recommendations. It should also include improvements in the quality of ACCT case management documentation , and the lessons learned from internal investigations into life-threatening incidents.” I have concerns that the recommendations will not be implemented and that past recommendations have been ignored.
(4) That despite my previous PFD reports the number of suicides at HMP Woodhill continue to rise.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to implement previous safety recommendations
Wider context from the report “(1)During the course of the evidence I was referred to the most recent report from the HM Inspector of Prisons that highlighted “Recommendations made by the Prisons and Probation Ombudsman following previous deaths in custody , such as the need to improve the quality of ACCT case management documentation for prisoners at risk of suicide or self harm, had not been implemented with sufficient rigour .
(2) Deaths at the prison from suicide and self harm continue to rise.
(3) The recommendation from the Inspectors is that there should be a “prison-wide strategy and action plan to reduce the number of self inflicted deaths and incidents of self harm should be developed urgently. This should be based on detailed data and trend analysis and include implementation of Prison and Probation Ombudsman recommendations. It should also include improvements in the quality of ACCT case management documentation, and the lessons learned from internal investigations into life-threatening incidents.” I have concerns that the recommendations will not be implemented and that past recommendations have been ignored.
(4) That despite my previous PFD reports the number of suicides at HMP Woodhill continue to rise.
” Open source report
Concerns raised 5 Failure to provide or record support for prisoners reporting bullying without naming alleged perpetrators View source Failure to investigate allegations of bullying View source Insufficient first-aid training among first-attending prison officers View source Ineffective implementation of the Tackling Bullying Behaviour policy in response to bullying complaints View source Failure to refer concerns to a MASH meeting when risk indicators are present View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Derrick Edward ROSE-FOWLER · 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
Derrick Edward ROSE-FOWLER was found hanging by his neck from his prison cell window on 5 June 2015 and was pronounced dead after being transferred to hospital. The concerns included the first attending prison officer not being first-aid trained, the handling of alleged bullying, and the failure to raise concerns about the deceased at a MASH meeting despite several relevant factors.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to provide or record support for prisoners reporting bullying without naming alleged perpetrators
Wider context from the report “(2) The TBB did not explicitly allow for or record that a prisoner, such as the deceased, who was not prepared to name names could nevertheless still be offered support . It is a concern that the reasons given by the various witnesses were not demonstrated to have been considered .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to investigate allegations of bullying
Wider context from the report “(3) At paragraph 19 of the final PPO report it states ‘there has been one other self-inflicted death at Stoke Heath, in the last 4 years – in March 2013. In the investigation into that death we found that the prison did not investigate allegations of bullying ’. For completeness the central issue at that inquest was in relation to the deceased’s mental health.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Insufficient first-aid training among first-attending prison officers
Wider context from the report “(1) Although on the facts of this case it made no difference to the outcome, the first prison officer on the scene was not first aid trained . The evidence at the inquest was that there was no national requirement for all prison officers to be first aid trained provided a certain proportion were .
(2) In hanging cases time is of the essence for CPR and if there is any significant delay by reason of the first attending prison officer not being first aid trained there is the risk of future deaths occurring .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Ineffective implementation of the Tackling Bullying Behaviour policy in response to bullying complaints
Wider context from the report “(1) There was evidence that bullying was ‘rife’. Whilst the majority of the evidence at the inquest indicated that the deceased was not himself being bullied there was some evidence that he was. The prison has a Tackling Bullying Behaviour (TBB) policy but there is concern as to how effective it was implemented on the complaints raised by the deceased himself that he was, in terms, being bullied .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to refer concerns to a MASH meeting when risk indicators are present
Wider context from the report “(4) Regardless of whether the TBB policy was appropriately implemented there was evidence that concerns relating to the deceased should have been raised at a MASH meeting . Factors which should have triggered such a referral were:
a. History of self-harm in 2014.
b. Recorded diagnoses of anxiety and depression.
c. An ACCT opened at HMP Featherstone in October 2014.
d. The intelligence report raised by the mental health nurse in March 2015.
e. The letter handed by the deceased to a prison officer in April 2015.
f. The refusal of the deceased to take prescribed medication.
g. The refusal of the deceased to attend scheduled GP appointments.
It could not be said that any such referral would have changed the outcome but there was evidence that something would have been done.
” Open source report
16 Mar 2016 Steven James May · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 10 Inadequate First Aid training for prison staff View source Selective emergency First Aid training among prison staff View source Lack of mental health experience and/or training among reception nursing staff View source Involvement of prison staff lacking relevant training or appropriate rank in the ACCT process View source Hesitancy to enter a cell during an emergency because of an instruction not to enter cells alone View source Failure to ensure medical professional attendance at First Care Reviews View source Failure of reception nursing staff to consult historical medical notes during reception interviews View source Limited accessibility of health and/or mental health care during weekends and Bank Holidays View source Reliance on verbal handovers rather than written records for prisoner information View source Failure to prepare sufficiently full ACCT assessment notes View source See 7 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Steven James May · 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
Steven James May died by hanging at HMP Ranby on 25 May 2015 at 01:45, after previously expressing suicidal intent and being placed on the ACCT programme. The report identified concerns about failures in reception health screening, ACCT documentation and reviews, information handovers, staff training and involvement, emergency first aid, cell-entry procedures, and access to health and mental health care.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Inadequate First Aid training for prison staff
Wider context from the report “(9) The inadequacy of First Aid training provided to prison staff in any event (namely, the administration of CPR by prison staff whilst the deceased was lying on a bed );
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Selective emergency First Aid training among prison staff
Wider context from the report “(7) The selective training of prison staff in emergency First Aid (namely the first member of prison staff on the scene of the death was not trained in the administration of CPR and was ignorant of the location of and method of use of defibrillators );
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 experience and/or training among reception nursing staff
Wider context from the report “(2) The lack of experience and/or training of reception nursing staff in the field of mental health ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Involvement of prison staff lacking relevant training or appropriate rank in the ACCT process
Wider context from the report “(5) The involvement in the ACCT process of prison staff possessing neither relevant training nor the appropriate rank ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Hesitancy to enter a cell during an emergency because of an instruction not to enter cells alone
Wider context from the report “(8) The hesitancy of the first member of prison staff on the scene to enter the deceased’s cell in apparent adherence to an instruction not to enter cells alone ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable 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 medical professional attendance at First Care Reviews
Wider context from the report “(6) The failure of prison staff to ensure the attendance of a medical professional at the First Care Review ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure of reception nursing staff to consult historical medical notes during reception interviews
Wider context from the report “(1) The failure of reception nursing staff , by reason of lack of training and/or instruction or lack of staff and/or time , to consult the deceased’s historical medical notes prior to or during the reception interview ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Limited accessibility of health and/or mental health care during weekends and Bank Holidays
Wider context from the report “(10) The accessibility of health and/or mental health care to inmates at weekends and during Bank Holidays .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 verbal handovers rather than written records for prisoner information
Wider context from the report “(4) Reliance by prison staff on verbal and/or oral handovers of information, rather than written records , regarding the deceased ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable 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 prepare sufficiently full ACCT assessment notes
Wider context from the report “(3) The failure of prison staff when preparing the ACCT document to prepare as full a note as possible . For example, to follow the subject areas suggested in the narrative accompanying sections 1-8 of the Assessment Interview ;
” Open source report
19 Jan 2016 Lee Stewart Rushton · Prevention of Future Deaths report Liverpool and the Wirral
View report summary
Concerns raised 1 Lack of policy or guidance requiring consideration of the ACCT care plan during mandatory ACCT review when a CSRA indicates single-cell placement for the protection of others 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
Lee Stewart Rushton · 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
Lee Stewart Rushton died aged 24 on 28 January 2015 after being found hanging from a ligature fashioned from a blanket in a cell at HMP Liverpool. The jury identified concerns including inadequate management of a recognised risk of self-harm or suicide, insufficient mental health and drug-dependency care, failures in ACCT procedures and communication, and missed opportunities to increase observations. The report also raises the need to clarify how ACCT care plans should be managed when a cell-sharing risk assessment indicates that a prisoner should be housed alone.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Lack of policy or guidance requiring consideration of the ACCT care plan during mandatory ACCT review when a CSRA indicates single-cell placement for the protection of others
Wider context from the report “When a prisoner is on an ACCT (Assessment, Care in Custody and Teamwork) and a CSRA (Cell Sharing Risk Assessment) indicates an inmate should be in a cell alone for the protection of others. What consideration should be given to the ACCT Care plan with regard to a mandatory ACCT review? Should this already be covered in policy or guidance consideration should be given to reminders being issued and or if necessary mandatory training across the prison estate in the light of the jury’s findings.
” Open source report
29 Dec 2015 Imran DOUGLAS · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 7 Lack of social worker knowledge of Transition Plans View source Failure to ensure YOT and YJB knowledge and expertise are considered in placements before completion of the Transition Plan View source Lack of accessible universal records throughout the offender pathway View source Disconnection between Looked After Child pathway planning and Transition Planning View source Failure to propose clinical interventions View source Failure to record clinical history and examination View source Failure of social workers to communicate directly with secure estate staff View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Imran DOUGLAS · 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
Imran Douglas died by suicide on 13 November 2013, on the fifth day of his detention at HMP Belmarsh, after being sentenced to 18 years. The report identified concerns about transition and placement arrangements, communication and information-sharing between agencies, access to electronic records, and the adequacy of a medical assessment and response to suicide risk.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Lack of social worker knowledge of Transition Plans
Wider context from the report “Evidence pointed to a disconnection between Looked After Child pathway planning and Transition Planning. A social worker said that the LAC plan was “potentially informative” but did not matter if it was not completed, but that now it is regarded as key and should be shared. One social worker said she did not know what a Transition Plan was . The current Head of Children's Social Care at LB Tower Hamlets said that staff pressures at the time had eased somewhat, but that under her leadership the interface with the secure estate was through the YJB and so social workers do not directly talk to the secure estate staff. This was despite the requirement for the two to work together in the Youth to Adult Transitions Framework. Given the lack of documented communications of the risks and concerns between YOT and Feltham in 2013, this evidence throws doubt on the reported improvements in training and changes in interagency communication have been put into operation since.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable 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 YOT and YJB knowledge and expertise are considered in placements before completion of the Transition Plan
Wider context from the report “I consider that there is an outstanding risk that, when a rising 18 enters the criminal justice system with insufficient time for the normal Transition Plan, and especially when staff are under pressure, that even with the changes in placements from courts that have been made, and the Joint National Protocol, the knowledge and expertise of the YOT and YJB may not be properly considered in a placement if the legal duty for placement has passed to the PMU before the Plan is complete .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 accessible universal records throughout the offender pathway
Wider context from the report “The jury criticised the lack of access of HMP Belmarsh to the E Asset system and the fact that key documents from the Secure Training Centre were never accessed by the secure estate . The lack of a universal system of records throughout the offender’s pathway results in information on risk not being known to others and may contribute to future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Disconnection between Looked After Child pathway planning and Transition Planning
Wider context from the report “Evidence pointed to a disconnection between Looked After Child pathway planning and Transition Planning . A social worker said that the LAC plan was “potentially informative” but did not matter if it was not completed, but that now it is regarded as key and should be shared. One social worker said she did not know what a Transition Plan was. The current Head of Children's Social Care at LB Tower Hamlets said that staff pressures at the time had eased somewhat, but that under her leadership the interface with the secure estate was through the YJB and so social workers do not directly talk to the secure estate staff. This was despite the requirement for the two to work together in the Youth to Adult Transitions Framework. Given the lack of documented communications of the risks and concerns between YOT and Feltham in 2013, this evidence throws doubt on the reported improvements in training and changes in interagency communication have been put into operation since.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable 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 propose clinical interventions
Wider context from the report “The GP did not record history or examination or propose any interventions despite being aware of the young age, long sentence and suicide warning form. The clinical review conducted as part of the Prison and Probation Ombudsman’s Report concluded that health care provision in HMP Belmarsh was below the standard expected.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable 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 clinical history and examination
Wider context from the report “The GP did not record history or examination or propose any interventions despite being aware of the young age, long sentence and suicide warning form. The clinical review conducted as part of the Prison and Probation Ombudsman’s Report concluded that health care provision in HMP Belmarsh was below the standard expected.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable 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 social workers to communicate directly with secure estate staff
Wider context from the report “Evidence pointed to a disconnection between Looked After Child pathway planning and Transition Planning. A social worker said that the LAC plan was “potentially informative” but did not matter if it was not completed, but that now it is regarded as key and should be shared. One social worker said she did not know what a Transition Plan was. The current Head of Children's Social Care at LB Tower Hamlets said that staff pressures at the time had eased somewhat, but that under her leadership the interface with the secure estate was through the YJB and so social workers do not directly talk to the secure estate staff . This was despite the requirement for the two to work together in the Youth to Adult Transitions Framework. Given the lack of documented communications of the risks and concerns between YOT and Feltham in 2013, this evidence throws doubt on the reported improvements in training and changes in interagency communication have been put into operation since.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue instructions preventing under-18 establishments from transferring young people to the young adult estate via courts.
Verbatim wording from the response “We have consequently reviewed this process and are now in the final stages of putting an agreement in place with the YJB to ensure that where there is no transition plan, the young person will return from court to the under 18 establishment, and subsequently move from there to the identified adult establishment. It should be noted that transition plan will, as now, be agreed between the two establishments and that NOMS Population Management Unit does not play the role in decisions over the placement of individuals that you suggest in your report. As a result of this work Governors of under 18 establishments will shortly be issued with instructions to cease all transition to the young adult estate via courts, in order to allow for effective transition planning for this cohort.” Source location 2015-0446-Response-by-NOMS
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete the agreement with the Youth Justice Board requiring young people without transition plans to return to youth custody before transfer to the identified adult establishment.
Verbatim wording from the response “We have consequently reviewed this process and are now in the final stages of putting an agreement in place with the YJB to ensure that where there is no transition plan, the young person will return from court to the under 18 establishment, and subsequently move from there to the identified adult establishment. It should be noted that transition plan will, as now, be agreed between the two establishments and that NOMS Population Management Unit does not play the role in decisions over the placement of individuals that you suggest in your report. As a result of this work Governors of under 18 establishments will shortly be issued with instructions to cease all transition to the young adult estate via courts, in order to allow for effective transition planning for this cohort.” Source location 2015-0446-Response-by-NOMS
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete formal assurance assessments of transition-process delivery against the Transitions Protocol requirements.
Verbatim wording from the response “In the meantime, you will be aware that with regard to the system of placements at transition, the NOMS’ Transitions Protocol, published in September 2012, sets out the process for transitioning young people from youth to adult custodial services. The protocol covers issues such as planning, information sharing and appropriate timescales, and describes how the involvement of the young person, their family and professionals from both youth and adult services must form a key part of the decision making process. The implementation of the protocol was supported through operational support visits to all under 18 establishments by NOMS young people’s group and in 2014 a Transitions service assurance module was completed jointly by the Youth Justice Board (YJB) and NOMS young people’s group to provide a formal assessment of delivery against the requirements.” Source location 2015-0446-Response-by-NOMS
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the Transitions Protocol and develop it into a Prison Service Instruction defining mandatory transition, safeguarding, assessment, information-sharing and collaborative-working procedures.
Verbatim wording from the response “NOMS is currently reviewing the transitions protocol with a view to developing it into a Prison Service Instruction (PSI) which will define the national and local procedures which governors must implement to meet the specific needs of young people who will transition to adult custody, with a particular focus on supporting effective assessments and information sharing as well as promoting collaborative working between the” Source location 2015-0446-Response-by-NOMS
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Roll out the Y2A Portal across England and Wales to improve information sharing between youth offending, probation and adult young offender services.
Verbatim wording from the response “Finally, it is accepted that a universal system of records conveyed by electronic communication between agencies would be desirable. However, there are practical and resource constraints that mean that it is not possible to implement such a system, and this is not the only way to make the improvements to information sharing that are necessary to mitigate risk and address your concern. As you will be aware from the inquest, the YJB has worked with NOMS to develop the ‘Y2A Portal’, which is a web-based system which aims to improve information sharing between Youth Offending Teams YOTs to probation services and adult YOIs. The Y2A portal has been successfully piloted with community services and is now being rolled-out across England and Wales.” Source location 2015-0446-Response-by-NOMS
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NOMS Population Management Unit does not make the individual placement decisions attributed to it.
Verbatim wording from the response “We have consequently reviewed this process and are now in the final stages of putting an agreement in place with the YJB to ensure that where there is no transition plan, the young person will return from court to the under 18 establishment, and subsequently move from there to the identified adult establishment. It should be noted that transition plan will, as now, be agreed between the two establishments and that NOMS Population Management Unit does not play the role in decisions over the placement of individuals that you suggest in your report. As a result of this work Governors of under 18 establishments will shortly be issued with instructions to cease all transition to the young adult estate via courts, in order to allow for effective transition planning for this cohort.” Source location 2015-0446-Response-by-NOMS
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Practical and resource constraints prevent implementing a universal electronic records system between agencies.
Verbatim wording from the response “Finally, it is accepted that a universal system of records conveyed by electronic communication between agencies would be desirable. However, there are practical and resource constraints that mean that it is not possible to implement such a system, and this is not the only way to make the improvements to information sharing that are necessary to mitigate risk and address your concern. As you will be aware from the inquest, the YJB has worked with NOMS to develop the ‘Y2A Portal’, which is a web-based system which aims to improve information sharing between Youth Offending Teams YOTs to probation services and adult YOIs. The Y2A portal has been successfully piloted with community services and is now being rolled-out across England and Wales.” Source location 2015-0446-Response-by-NOMS
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The agreed multidisciplinary casework model provides coordinated care and effective transition preparation for young people in custody.
Verbatim wording from the response “Turning to inter-agency working, there is an agreed casework model through which each under 18 establishment deliver a young person’s sentence plans. This model is underpinned by multidisciplinary integration and effective communications to meet the needs of each young person in custody. The casework teams act as the medium for co-ordinating the various specialist departments involved in the young person’s care within the establishment and the wide range of external stakeholders, including the local authority with responsibility for the individual’s care. This provides a single, cohesive approach for managing the young person throughout the period in custody and effectively preparing them for transition to ensure that the process runs smoothly and is as positive as it can be.” Source location 2015-0446-Response-by-NOMS
Open published response
25 Nov 2015 Dean Ronald Edmund BOLAND · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 12 Failure to monitor prisoners overnight View source Failure of prison, health and DART workers to share drug issue information adequately View source Insufficient exercise-area officer staffing for package security View source Insufficient exercise-area netting and package interception View source Failure to inform prison officers of positive drug test results View source Inadequate overnight security officer capacity for B wing View source Insufficient drug-dog coverage for screening prisoners and visitors View source Failure to check prisoners' mouths during general medicine administration View source Lack of prison officer awareness and understanding of drug issues View source Insufficient cell searching for drugs View source Lack of capability to screen incoming prisoners and visitors for concealed drugs View source Unavailability of compact drug results to DART workers 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.
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AI-generated summary
Dean Ronald Edmund BOLAND · 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
Dean Ronald Edmund Boland was found unresponsive in his cell at HMP Birmingham on 17 April 2015 and was pronounced dead shortly afterwards. Post-mortem examination confirmed multiple drugs in his system, and the inquest concluded that he died from mixed drug toxicity. The principal concerns included inadequate awareness, communication, monitoring, searching and security measures relating to drug use within the prison.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to monitor prisoners overnight
Wider context from the report “5. Prisoners on B wing are not viewed or monitored at all overnight unless they are on an ACCT . This gives them a considerable period of time to smoke and use drugs knowing there will be no supervision or observation from prison officers .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure of prison, health and DART workers to share drug issue information adequately
Wider context from the report “2. There is a lack of multi-disciplinary approach to drug issues within the prison . The evidence heard at the inquest confirmed that prison officers, health workers and DART workers do not adequately discuss trends and general drugs issues to ensure all staff are up to date and aware of the problems . It is accepted that patient’s confidentiality needs to be maintained but it is essential to discuss trends and significant events in a multi-disciplinary way.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 exercise-area officer staffing for package security
Wider context from the report “10. The prison should investigate whether 3 prison officer on duty in the exercise area is sufficient for 172 prisoners given the number of packages that are thrown over the walls every week .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 exercise-area netting and package interception
Wider context from the report “9. There are several exercise areas at the prison. Only two have netting . Further consideration needs to be given to netting other areas given the number of packages being thrown over the wall and then secreted by prisoners on their person. The inquest heard that only a small proportion of packages are seized as they come over the wall .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to inform prison officers of positive drug test results
Wider context from the report “8. Prison officers are unaware of positive drug test results and therefore unable to take any action in response .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 overnight security officer capacity for B wing
Wider context from the report “6. The prison deploy a security officer to B wing at night (172 prisoners) .This person is unable to interact with prisoners and is only there to answer call bells . This seems inadequate given that this group of prisoners are at high risk of drug use particularly at night when there are no cell checks.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 drug-dog coverage for screening prisoners and visitors
Wider context from the report “12. Birmingham prison has 2 drug dogs who work on a shift pattern. This means not every area in the prison can be covered as only one dog is on duty at any one time . Given that these dogs are the only current mechanism for identifying certain drugs consideration needs to be given to having more dogs so that prisoners and visitors coming into the prison will always be screened .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable 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 check prisoners' mouths during general medicine administration
Wider context from the report “3. General medicine administration does not involve a check of the mouth so prisoners can easily conceal tablets to sell later .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Lack of prison officer awareness and understanding of drug issues
Wider context from the report “1. There was a general lack of awareness and understanding of the drugs issues in the prison by prison officers . Two prison officers who worked on B wing said they were unaware of any problems with prisoners using illicit drugs including general medications . Prison officers need a comprehensive education program to understand what drugs are being used and sold and how prisoners come by those drugs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 cell searching for drugs
Wider context from the report “4. Cell searches only take place for a certain number of cells each month on a random basis as prescribed by NOMS, or for targeted cells when there is sufficient intelligence . Intelligence searches only take place when there is at least 2 pieces of intelligence . Given the extent of the drug problem on B wing this seems insufficient .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 capability to screen incoming prisoners and visitors for concealed drugs
Wider context from the report “11. At present there is no ability to search or screen prisoners or visitors for drugs concealed on their person when they come into prison . Given that this is a major source of drugs coming into the prison further consideration need to be given, on a national level, as to how concealed drugs can be identified for example with the use of a full body scanner. The current scanner can only identify metal objects .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 compact drug results to DART workers
Wider context from the report “7. DART workers are currently unable to access compact drug results as workers are unable to log onto the computer .
” Open source report
2 Nov 2015 Richard Scott Green · Prevention of Future Deaths report Cumbria
View report summary
Concerns raised 3 Failure of clinicians to review patients’ historical medical records View source Failure of SystmOne to provide usable search and clear flagging of important historical information View source Lack of a reliable tool for assessing depression in 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
Richard Scott Green · 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
Richard Scott Green was found hanged in his cell at Haverigg Prison on 9 May 2014, using a ligature made from a torn bed sheet. The jury found that bullying and debt had contributed to his death but was not satisfied that he intended to kill himself. The report raised concerns that his documented history of self-harm and apparent suicide attempts was not recognised or acted upon by prison medical professionals, with missed opportunities to assess and manage the risk he presented.
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 clinicians to review patients’ historical medical records
Wider context from the report “I was clear that serious incidents of self-harm/suicide attempts from 2007 and 2013 were recorded on his SystmOne records. These do not appear to have been recognised or acted upon by various medical professionals in the prison system.
This meant that a nurse at screening had not read the records, neither had a GP or a mental health nurse who later carried out an assessment. The result was that throughout his prison term at Haverigg no one was aware of the history and the risk he presented. As a result, there were missed opportunities which might have made a difference. Evidence showed that
a) there appeared to be no reliable tool to help assess depression in a prisoner (community tools being unsatisfactory).
b) Although entries were there to be seen on System One, none of the clinicians saw them. Pressure of work and the time needed to check were reasons cited, together with lack of resources.
It seems SystmOne was not easy to use, some staff being unaware they could “search” and an absence of a way to clearly flag important historical information to ensure it was at the clinicians’ finger tips.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure of SystmOne to provide usable search and clear flagging of important historical information
Wider context from the report “I was clear that serious incidents of self-harm/suicide attempts from 2007 and 2013 were recorded on his SystmOne records. These do not appear to have been recognised or acted upon by various medical professionals in the prison system.
This meant that a nurse at screening had not read the records, neither had a GP or a mental health nurse who later carried out an assessment. The result was that throughout his prison term at Haverigg no one was aware of the history and the risk he presented. As a result, there were missed opportunities which might have made a difference. Evidence showed that
a) there appeared to be no reliable tool to help assess depression in a prisoner (community tools being unsatisfactory).
b) Although entries were there to be seen on System One, none of the clinicians saw them. Pressure of work and the time needed to check were reasons cited, together with lack of resources.
It seems SystmOne was not easy to use, some staff being unaware they could “search” and an absence of a way to clearly flag important historical information to ensure it was at the clinicians’ finger tips.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Lack of a reliable tool for assessing depression in prisoners
Wider context from the report “I was clear that serious incidents of self-harm/suicide attempts from 2007 and 2013 were recorded on his SystmOne records. These do not appear to have been recognised or acted upon by various medical professionals in the prison system.
This meant that a nurse at screening had not read the records, neither had a GP or a mental health nurse who later carried out an assessment. The result was that throughout his prison term at Haverigg no one was aware of the history and the risk he presented. As a result, there were missed opportunities which might have made a difference. Evidence showed that
a) there appeared to be no reliable tool to help assess depression in a prisoner (community tools being unsatisfactory).
b) Although entries were there to be seen on System One, none of the clinicians saw them. Pressure of work and the time needed to check were reasons cited, together with lack of resources.
It seems SystmOne was not easy to use, some staff being unaware they could “search” and an absence of a way to clearly flag important historical information to ensure it was at the clinicians’ finger tips.
” Open source report
Concerns raised 2 Failure to comply as closely as possible with the requirement for medical review of prisoners under continuous observation View source Failure to ensure that ACCT review attendees read recent ongoing observations View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Andrew Douglas Frere · 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 Frere self-harmed while imprisoned at HMP Moorland and was managed under the ACCT procedure. He died on 10 February 2014 after suspending himself by a ligature formed from a bedsheet in his cell. Concerns were raised about failure to follow, or closely approximate, the requirement for regular medical review during continuous observation, and about ACCT reviewers not being specifically instructed to read recent ongoing observations.
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 comply as closely as possible with the requirement for medical review of prisoners under continuous observation
Wider context from the report “(1) Prison Service Instruction 64/2011 requires that prisoners under continuous observation should be seen by a doctor very 24 hours. The evidence given at the inquest indicated that this was not practicable, and the rule was widely recognised as not being so practicable.
My concern is less or to the apparent impracticability of the PSI, but more that, this impracticability having been recognised, the rule appears to have been ignored, rather than any attempt having been made at least to comply as closely as possible . Since Andrew Frere’s death this is now done at HMP Moorland by having nursing staff see the prisoner when a doctor is not available, but the problem with the impracticability of the PSI appears to be national, rather than a local one, and ought to be the subject of some sort of guidance at national level.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure that ACCT review attendees read recent ongoing observations
Wider context from the report “(2) The PSI does not appear to include any specific instruction that the case manager, or others attending ACCT review, should ensure that they read the ongoing observations, at least as far back as the previous review , in order to ensure that they are aware of recent events when they carry out such a review.
My concern is that potentially important information, which might affect decisions taken at the review, may be missed if the recent observations are not read .
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations