5 Aug 2015 Rubel Ahmed · Prevention of Future Deaths report Central Lincolnshire
View report summary
Concerns raised 6 Failure to ensure detention staff awareness of significant changes in detainees' circumstances View source Failure to prevent overnight locking of detainees in their rooms View source Lack of regular detention awareness refresher training View source Provision of electrical items with leads that can be used as ligatures View source Insufficiently robust detention awareness training View source Lack of protected time for personal officers to carry out assigned duties 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
Rubel Ahmed · 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
Rubel Ahmed, who was detained at Morton Hall Immigration Removal Centre, was found hanging in his room on the evening of 5 September 2014 and was pronounced deceased shortly after midnight on 6 September 2014. The concerns included overnight locking of detainees in rooms, the adequacy of detention-awareness training, staff awareness of changes in detainees’ circumstances, insufficient protected time for personal officers, and the use of electrical leads that could be used as ligatures.
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 detention staff awareness of significant changes in detainees' circumstances
Wider context from the report “iii. STAFF AWARENESS OF CHANGES IN DETAINEES CIRCUMSTANCES INCLUDING REMOVAL DIRECTIONS:
It was disclosed at the Inquest that staff members, who dealt with Mr Ahmed on the evening of 5th September, 2014 were not aware that he had been served with removal directions . Had staff been aware of this information it may have resulted in Mr Ahmed being monitored more comprehensively than was the case.
My concerns relate to there being a need to implement a robust system to ensure that all relevant detention staff at Morton Hall IRC are aware of significant changes in detainees circumstances, including the service of removal directions upon them .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent overnight locking of detainees in their rooms
Wider context from the report “i. THE LOCKING OF SOME DETAINEES IN THEIR ROOMS OVERNIGHT:
In 2013, H.M Inspectorate of Prisons inspected IRC Morton Hall and recommended that detainees should not be locked into cells (rooms) and should not be restricted to units in the early evening. Despite this recommendation, those in the Windsor Unit, in which Mr Ahmed resided, were locked into their rooms from 8:30pm to 8:00am on the following morning . This situation prevailed at the time of Mr Ahmeds death. Whilst it was clear that significant efforts had been made to comply with the above HMIP recommendation, detainees in the Windsor Unit were still being locked into their rooms overnight at the time of the Inquest . My concern relates to whether the above HMIP recommendation has now been fully complied with and if not when compliance will be achieved. I consider that the practice of locking detainees in their rooms in the evenings and/or overnight should be discontinued as soon as is practically possible at Morton Hall I.R.C.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Lack of regular detention awareness refresher training
Wider context from the report “ii. DETENTION AWARENESS TRAINING:
I am concerned that the detention awareness training given to the staff at Morton Hall I.R.C was not sufficiently robust to be of continuing assistance to staff in their understanding of detainees needs or to have an ongoing impact on their working practices. Further, little or no provision had been made to provide regular refresher training . I consider that there is a need for an urgent review of the provision of detention awareness training to detention staff at Morton Hall IRC with a view to effective training and refresher training courses being provided.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Provision of electrical items with leads that can be used as ligatures
Wider context from the report “v. USE OF ELECTRICAL ITEMS IN ROOMS:
Evidence at the Inquest established that Mr Ahmed utilised the electrical lead on his kettle to form a ligature with which he hanged himself. The electrical lead was noted to be two feet six inches in length. The lead could have been very much shorter and thus have avoided the risk of it being utilised as a ligature . This issue needs to be reviewed throughout Morton Hall IRC.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Insufficiently robust detention awareness training
Wider context from the report “ii. DETENTION AWARENESS TRAINING:
I am concerned that the detention awareness training given to the staff at Morton Hall I.R.C was not sufficiently robust to be of continuing assistance to staff in their understanding of detainees needs or to have an ongoing impact on their working practices . Further, little or no provision had been made to provide regular refresher training. I consider that there is a need for an urgent review of the provision of detention awareness training to detention staff at Morton Hall IRC with a view to effective training and refresher training courses being provided.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 protected time for personal officers to carry out assigned duties
Wider context from the report “iv. PERSONAL OFFICER DETAIL:
Despite the fact that Mr Ahmed had been allocated a Personal Officer it was abundantly clear that the officer had spent very little time with him, owing to other work pressures. It was also evident that there was no adequate system at Morton Hall for ensuring that staff have protected time to carry out this important work to enable detainees to discuss sensitive or distressing issues with an officer who was familiar to them.
I consider that this situation needs to be reviewed to ensure that personal officers at Morton Hall IRC assigned to detainees are given protected time to carry out these duties.
” Open source report
12 May 2015 Paul Mc Guigan · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 16 Unavailability of enhanced criminal-record disclosures for overseas armed private security employment View source Lack of recording of pre-conviction disclosures View source Lack of understanding of overseas armed close protection work View source Lack of guidance and transfer arrangements for MAPPA-triggering offenders View source Lack of computer categorisation for close protection occupations View source Lack of clear procedure and funding responsibility for independent forensic psychiatric reports View source Lack of training for officers and civilian employees on disclosure procedures View source Failure to understand and operate the Notifiable Occupation Scheme View source Failure to consider disclosure to employers View source Inadequate and infrequent formal supervision of newly qualified offender managers View source Lack of a national system and contact point for obtaining military information View source Failure to record discussions among key professionals View source Failure of agencies to check and share available information before multi-agency meetings View source Incomplete and unclear procedure for the Common Law Police Disclosure Scheme View source Misunderstanding of residence conditions for offender monitoring View source Lack of recording of offenders' bail conditions View source See 13 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
Paul Mc Guigan · 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 Mc Guigan was shot and unlawfully killed by a close protection work colleague on 9 August 2009 while both were working as armed private security contractors in Baghdad. The report identified missed opportunities and failings in managing the offender’s escalating offending behaviour and risk, and stated that G4S had not adequately vetted him before deployment. Concerns also included failures in information sharing, recording bail conditions, police disclosure processes, and the supervision and risk assessment of offenders.
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 enhanced criminal-record disclosures for overseas armed private security employment
Wider context from the report “I also have a concern that an employer on a private security contract at home has regulated by the SIA and a private security employed overseas [unregulated save for voluntary schemes such as International Code of Conduct for Private Security Service Providers 2010 [ICoC] and accredited certification to the standard ANSI/ SSlS PSC. 1-2012] is not entitled or able to obtain an enhanced CRB and would only ever receive a Standard disclosure on a pre employment check.
It concerns me in particular that in respect of employing on individual on an armed contract then consideration should be given to enabling Private Security Companies a route to obtaining an enhanced disclosure.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 recording of pre-conviction disclosures
Wider context from the report “It is clear that within GMP there was no recording anywhere as to when / if any pre convictions disclosures were made . It is important that there is a system of recording in this scenario and also to whom the disclosure is made. At present no-one can provide any information as to the number of detail of pre-conviction disclosures. In addition this means that officers who may be dealing with someone who has been arrested have no way of knowing if such a pre-conviction disclosure has ever been made.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of overseas armed close protection work
Wider context from the report “In addition I have a concern that there is a complete lack of understanding by the Police and Probation / NOMS as to what close protection work overseas involves and in particular when this involves work on armed contracts .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance and transfer arrangements for MAPPA-triggering offenders
Wider context from the report “It concerns me to ensure that there is clear guidance given by NOMS to the private community rehabilitation companies [e.g. in Manchester Purple Futures] as to assessment of risk and for offenders who then do trigger MAPPA concerns that should be being supervised or assessed for eligibility under MAPPA to be transferred to be supervised by the National Probation Service.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 computer categorisation for close protection occupations
Wider context from the report “In respect of the GMP computer system and in respect of occupations that are regulated and require licensing by the SIA, there is no categorisation on the computer for “CLOSE PROTECTION” . Indeed the Court heard that there was some confusion and lack of understanding from many people as to what this occupation actually meant. Close protection work is a separate category of employment within the UK that the SIA regulates and the police system should reflect the occupations subject to regulation. It is important that the police and NOMS have a clear understanding as to what close protection work is to inform risk and risk assessment.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Lack of clear procedure and funding responsibility for independent forensic psychiatric reports
Wider context from the report “It concerns me that there is not a clear practice and procedure operating within the Court or probation system, including funding responsibility, for obtaining an Independent Forensic Psychiatric Report , particularly in circumstances where a defendant is remanded on bail in the community.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Lack of training for officers and civilian employees on disclosure procedures
Wider context from the report “At present in respect of a replacement scheme in respect of clarifying the Common Law Police Disclosure Scheme I heard evidence as to the process GMP are undergoing in respect of a revised Procedure relating to Notifiable Occupations but this is far from complete and less than clear as to how it will operate and the training that will be given to officers / GMP civilian employees . The Court was also advised that at no stage has legal advice been taken from the force in-house legal team on the proposed scheme, even though this is a difficult legal area.
It is important that GMP and all forces have a recognised procedure in respect of having a scheme but also training officers to operate that scheme. It is imperative also that the SIA understand how and when each police force will be making disclosures under the Common Law Police Disclosure Scheme.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable 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 understand and operate the Notifiable Occupation Scheme
Wider context from the report “In my judgment there was a complete misunderstanding by GMP in respect of the operation of the Notifiable Occupation Scheme HOC 6/2006 .
Of immense concern also the complete failure for a period of approximately 18 months to make any post conviction notifications under the Notifiable Occupation Scheme , which was it transpired, formally withdrawn by the Home Secretary Theresa May MP in March 2015.
I heard and received evidence from the SIA that they were not aware that a regulatory gap existed in respect of the Police’s understanding of the scheme and notifications to themselves . The evidence I heard suggests that such a gap exists at GMP and has done so for in excess of 18 months.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to consider disclosure to employers
Wider context from the report “In respect of the period of time when Post conviction disclosures were made [before this “back office” function ceased 18 months ago] these were only ever disclosures made to the Regulatory body and consideration never appears to have been given within GMP to disclosure to employers . Given the lack of understanding as to whom some regulatory bodies have responsibility for, this is important.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Inadequate and infrequent formal supervision of newly qualified offender managers
Wider context from the report “I heard evidence that the Offender Manager was newly qualified and her formal supervision was inadequate and infrequent . This concerns me. It is important that newly qualified offender managers receive appropriate formal supervision .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Lack of a national system and contact point for obtaining military information
Wider context from the report “My concern is to ensure that there is a system, protocol and point of contact for every offender manager nationally [including the private rehabilitation companies now operating as offender managers] that is well known as to who to contact to within the Ministry of Defence to obtain military information .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to record discussions among key professionals
Wider context from the report “In addition I heard evidence and it concerns me that in advance of the Multi Agency meeting convened due to concerns as to the Offenders risk, key professionals had had discussions, telephone calls and meetings and I was concerned by the failure to record and document these important discussions , to ensure clarity, understanding and consistency. It is important when key professionals have discussions that these are documented and recorded .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure of agencies to check and share available information before multi-agency meetings
Wider context from the report “It is important irrespective of who is the lead agency at a Multi Agency Meeting that each agency invited to attend checks information held on systems and records to which they have access and provides all this information to a multi agency meeting to ensure that a full and informed assessment of risk takes place and the fullest possible informed information sharing.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 and unclear procedure for the Common Law Police Disclosure Scheme
Wider context from the report “At present in respect of a replacement scheme in respect of clarifying the Common Law Police Disclosure Scheme I heard evidence as to the process GMP are undergoing in respect of a revised Procedure relating to Notifiable Occupations but this is far from complete and less than clear as to how it will operate and the training that will be given to officers / GMP civilian employees. The Court was also advised that at no stage has legal advice been taken from the force in-house legal team on the proposed scheme, even though this is a difficult legal area.
It is important that GMP and all forces have a recognised procedure in respect of having a scheme but also training officers to operate that scheme. It is imperative also that the SIA understand how and when each police force will be making disclosures under the Common Law Police Disclosure Scheme.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Misunderstanding of residence conditions for offender monitoring
Wider context from the report “I also heard evidence that a GMP officer believed that Bail with a condition of residence was different to “bail live and sleep each night”. It is of concern that there is a misunderstanding within GMP as to what a condition of residence means and how this relates to the monitoring of offenders .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Lack of recording of offenders' bail conditions
Wider context from the report “I heard evidence that in respect of GMP systems and processes there was nowhere on the GMP computer system where bail conditions are recorded , although this used to be possible. It is of concern that there is no system of recording on the GMP computer of offenders bail conditions so that this information can be known by officers and appropriately shared.
” Open source report
21 Apr 2015 Anthony Peter Kristian Garrett · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 2 Dangerous and potentially life-threatening effects of consuming synthetic cannabinoids View source Readily available synthetic cannabinoids legally and commonly sold as herbal incense 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
Anthony Peter Kristian Garrett · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Anthony Peter Kristian Garrett collapsed after smoking Cherry Bomb, a substance marketed as herbal incense, after drinking alcohol throughout the day. He was transported to hospital, never regained consciousness, and died the following day. The report raised concerns that synthetic cannabinoids are readily available, commonly sold as herbal incense, and can be dangerous and potentially life-threatening when misused.
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 Dangerous and potentially life-threatening effects of consuming synthetic cannabinoids
Wider context from the report “2. I have concerns that Synthetic Cannabinoids are readily available substances in the community, which are legally and commonly sold as herbal incense. They are sold with a warning that they are not for human consumption, but are misused and consumed by people. Consequently they can be dangerous and potentially life threatening to those who use them in this 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 Readily available synthetic cannabinoids legally and commonly sold as herbal incense
Wider context from the report “2. I have concerns that Synthetic Cannabinoids are readily available substances in the community, which are legally and commonly sold as herbal incense . They are sold with a warning that they are not for human consumption, but are misused and consumed by people . Consequently they can be dangerous and potentially life threatening to those who use them in this way.
” Open source report
9 Mar 2015 Craig Douglas Bell · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 7 Failure to use CCTV monitoring as an adjunct to ACCT observation procedures View source Failure to share timely information about risk and suicidal or self-harming behaviour between clinical and HMPS staff View source Lack of psychological therapy identification and treatment for prisoners with personality disorders or related traits View source Lack of suitably senior psychiatric clinician attendance at discharge case reviews View source Insufficient availability of safer cells across prison wings for prisoners on ACCT View source Unavailability of cells or facilities fitted with CCTV monitoring View source Lack of graduated risk management planning after transfer to an ordinary wing location View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Craig Douglas Bell · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Craig Douglas Bell was found dead in his cell at HMP Manchester on 13 December 2012 after taking his own life by hanging using a self-constructed ligature. He had a history of self-harm and suicidal ideation and was subject to ACCT procedures. The principal concerns included inadequate sharing of risk information, insufficient senior psychiatric involvement in discharge planning, the lack of a graduated risk-management plan, and limited availability of safer or CCTV-monitored cells for prisoners at risk of 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 Failure to use CCTV monitoring as an adjunct to ACCT observation procedures
Wider context from the report “6. In 2011 there were a limited number of cells which had been fitted with CCTV monitoring cameras. Very sadly Anthony Raymond Gillard was found dead in such a cell on the 24 December 2011 but that the use of CCTV was not part of his observation regime although he was subject to ACCT procedures . No one looked at or considered the CCTV pictures until after his death but they clearly demonstrated that he had been suffering the effects of over sedation from opiate drugs which no witness had seen or noticed. The use of CCTV monitored cells was discontinued after his death and was not available at the time of Mr Bell’s death . One reason given was that if they were used it required a Prison Officer to be monitoring the CCTV images constantly 24 hours a day. They could , of course , be used as an adjunct or in addition to usual ACCT observation procedures. This would not require constant CCTV monitoring. NOMS have replied to the court’s Regulation 28 PFD report and a copy is attached. I am concerned that if such cells/facilities are not provided and used then there is a risk that prisoners on ACCT’s will continue to be able to kill themselves. The same considerations would apply nationally to the entire HMPS estate. I attach copies of the NOMS response to my Regulation 28 PFD and letter under paragraphs 37/38 of the Chief Coroner’s guidance in relation to Mr Gillard’s death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to share timely information about risk and suicidal or self-harming behaviour between clinical and HMPS staff
Wider context from the report “2. I am concerned that the appropriate sharing of information relating to risk and suicidal or self harming behaviour did not take place between the clinical team and HMPS staff . For example, the direct threat of suicide made at the review on the 27 November 2012 was not disclosed to HMPS staff. Appropriate, timely mutual information exchange had not taken place and there is a concern that this may be vital but may be overlooked if steps are not taken to make this a matter of routine. It means that clinical staff have to be able to review the clinical record appropriately and share information with their HMPS colleagues.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 psychological therapy identification and treatment for prisoners with personality disorders or related traits
Wider context from the report “1. The evidence established a significant unmet need for psychological therapies to treat patient prisoner suffering from personality disorders or those suffering from traits of such personality disorders. These prisoners are recognised as being at higher risk of self harm ( which may ultimately result in death ) or suicide. Without NHS Commissioners allocating more resources to identifying and treating such patients there is a concern that further prisoners suffering from these conditions will end up deliberately or accidentally killing themselves.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 suitably senior psychiatric clinician attendance at discharge case reviews
Wider context from the report “3. I am concerned at the lack of attendance of the Consultant Psychiatrist or a suitably qualified and experienced junior colleague at the discharge case review/meeting . In a case of patient still on an ACCT and being discharged to an ordinary wing location without as senior clinician being able to attend and participate in the discharge case review , risk assessment at that stage and risk planning. In this case there was no attendance on the 6 December 2012 and no clinician had seen him since 27 November 2012. This would allow a more sophisticated and timely assessment of risk at that time. Measures to try and reduce or mitigate the risks could then be discussed and put in place in a graduated manner. It is appreciated that such case reviews may have to be rearranged so as to facilitate full attendance. The court has previously identified the concern arising from that fact that no senior clinician took the opportunity at the appropriate time to stand back and take an overall view of the entire circumstances and the risks presented.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Insufficient availability of safer cells across prison wings for prisoners on ACCT
Wider context from the report “5. At the present time the HCC caters for some 22 patient prisoners and has 10 safer cells. I am concerned that the prison has a very limited number of safer cells on a limited number of other wings . At the present time there are no safer cells on all the wings ( invariably single occupancy designed to minimise the risk of using ligatures ). If prisoners are subject to ACCT’s and either transferred from one wing to another or transferred from the HCC to an ordinary wing location ( for what ever reason ) there is no half way house facility providing increased levels of safety . The provision of safer cells has demonstrably reduced the opportunity for fatal self harming in the over whelming majority of cases. Without HMPS investing in the provision of safer cells on every wing or of an increased number of wings there is a concern that prisoners will continue to kill themselves in non safer cells when they are on ACCT’s. The same considerations would apply nationally to the entire HMPS estate.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Unavailability of cells or facilities fitted with CCTV monitoring
Wider context from the report “6. In 2011 there were a limited number of cells which had been fitted with CCTV monitoring cameras. Very sadly Anthony Raymond Gillard was found dead in such a cell on the 24 December 2011 but that the use of CCTV was not part of his observation regime although he was subject to ACCT procedures. No one looked at or considered the CCTV pictures until after his death but they clearly demonstrated that he had been suffering the effects of over sedation from opiate drugs which no witness had seen or noticed. The use of CCTV monitored cells was discontinued after his death and was not available at the time of Mr Bell’s death . One reason given was that if they were used it required a Prison Officer to be monitoring the CCTV images constantly 24 hours a day. They could , of course , be used as an adjunct or in addition to usual ACCT observation procedures. This would not require constant CCTV monitoring. NOMS have replied to the court’s Regulation 28 PFD report and a copy is attached. I am concerned that if such cells/facilities are not provided and used then there is a risk that prisoners on ACCT’s will continue to be able to kill themselves. The same considerations would apply nationally to the entire HMPS estate. I attach copies of the NOMS response to my Regulation 28 PFD and letter under paragraphs 37/38 of the Chief Coroner’s guidance in relation to Mr Gillard’s death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Lack of graduated risk management planning after transfer to an ordinary wing location
Wider context from the report “4. I am concerned by the lack of planning or consideration of a graduated risk management plan in such circumstances . This was identified by the clinical reviewer. In other words increased frequency of day time interactions and throughout the whole day and MHIT and Psychiatrist contacts very shortly after the move . In this case the deceased was on the waiting list for a MHIT contact and was due to be seen within 2 weeks by the Psychiatrist.
” Open source report
28 Dec 2014 Alex Kelly · Prevention of Future Deaths report Mid Kent and Medway
View report summary
Concerns raised 28 Failure to provide complete information and records for safer regimes meetings View source Failure to verify medication ingestion before recording administration View source Failure to transfer documentation and emails onto Framework View source Failure to recognise distress communicated through behaviour View source Failure to recognise conflict between behaviour plans and adjudications View source Failure of YOT keyworkers to understand custodial welfare responsibilities View source Failure to use holistic safe-management planning when interventions are ineffective View source Inflexible cell-entry requirements during urgent safeguarding concerns View source Lack of forensic psychiatric assessment before custodial placement View source Conflict between ACCT and disciplinary procedures View source Delays in allocating a named social worker and escalating allocation difficulties View source Incomplete recording of mental-health in-reach contacts on System One View source Failure to share medication non-compliance and its potential effects View source Lack of a system for flagging or diverting urgent communications during staff absence View source Failure to seek advice before disciplinary action indicated increased self-harm risk View source Failure to understand available safe-management options View source Failure to highlight significant events in ongoing safeguarding records View source Failure to involve outside agencies and carers in safeguarding View source Failure to reconcile inconsistent secure-placement recommendations View source Failure to inform and involve agencies and carers in custodial welfare management View source Failure of ACCT reviews to address reasons for behaviour View source Failure to understand YOT authority to initiate secure-estate transfers View source Failure to escalate interagency shortcomings affecting YOT management View source Failure to adopt a holistic approach to custodial support View source Failure to understand corporate parenting responsibilities for children in custody View source Inconsistent recording of significant events across safeguarding records View source Failure to flag medication non-compliance for clinical and custodial action View source Failure to recognise or report significant incidents and disclosures View source See 25 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
Alex Kelly · 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
Alex Kelly, a vulnerable 15-year-old looked-after child, died in hospital after suspending himself from a ligature made from his shoelaces while detained at Cookham Wood Young Offenders Institution. The report identified concerns about the lack of a forensic psychiatric assessment, failures in communication and information sharing, weaknesses in the ACCT safeguarding process, conflicts between disciplinary procedures and suicide prevention, and inadequate management of his medication and welfare.
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 complete information and records for safer regimes meetings
Wider context from the report “Re: Secretary of State for Justice
Alex Kelly a vulnerable looked after child of 15 years with complex unresolved emotional issues and unmanaged mental health issues was sentenced to a Detention and Training Order to be served at a Young Offender’s Institution without the benefit of a forensic psychiatric assessment. Whilst I heard evidence from a psychiatrist associate of Cookham Wood YOI that the mental health in-reach team were able to address Alex’s mental health needs whilst in custody, I am aware of the deaths of a number of other children in custody who similarly had not had forensic psychiatric assessments and it is for this reason I am reporting the concern. Whilst hearing evidence in relation to lessons learned I heard from the Service Manager of Medway Youth Offending Team that they have now secured the services of a psychiatric mental health nurse to assist them in the effective management of the young people for whom they have responsibilities which I was told was proving effective and is to be continued.
Alex Kelly was under an ACCT between the 23rd December 2011 and 3rd January 2012 and 6th January 2012 until his death. During the operation of the ACCT there was a continued conflict between the ACCT process and disciplinary procedures; outside agencies and carers were not asked to contribute; specific acts by Alex were seen as obstructive/challenging behaviour rather than signs of distress or a means of communicating that he needed help (his foster carers who had not been asked to contribute had some experience of Alex using non-verbal methods of communication); the ACCT reviews tended to focus on addressing specific or recent behaviours rather than the reason for the behaviour; although Alex was frequently mentioned at weekly safer regimes multidisciplinary meetings, a holistic approach was never adopted as to how he could best be supported or whether the YOI could support his needs.
Re: Tower Hamlets
1. Allocation
a) Alex Kelly was without a named social worker for a period of two months at a time when he was in danger of being sent to custody and after he was sent to custody. Difficulties in allocation were not escalated to senior management
2. IT
a) Social workers did not transfer documentation including emails onto Framework in a timely manner or at all
b) There was no system in place for ensuring that urgent electronic communications were flagged/diverted when the recipient was absent from work
3. Custody
a) Social workers did not all appear to appreciate that their responsibilities as Corporate Parent included a role in a looked after child’s welfare whilst in custody
Re: Medway Youth Offending Team
1. Involvement with other agencies
a) Shortcomings in other agencies which affected the ability of the YOT to manage the young person were not brought to the attention of management
2. Placement within the Secure Estate
a) There were inconsistencies in recommendations as to placement in a STC/YOI which were not reconciled
b) Youth Offending Team keyworkers did not all appear to appreciate that their responsibilities included a role in the young person’s welfare whilst in custody
c) Members of the Youth Offending Team did not all appear to appreciate that the Youth Offending Team could initiate a transfer within the secure estate
3. Caseworker based at Cookham Wood YOI
a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person
b) Although involved in the ACCT reviews the caseworker was unaware of the range of options available to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews
c) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release
Re: Cookham Wood YOI
1. Communication with outside agencies
a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person
2. ACCT
a) Officers were inconsistent in the recording of significant events; entries being made in either the wing observation log, ACCT ongoing record or not at all
b) At least one officer did not appear to appreciate the importance of significant incidents/disclosures or report them
c) Significant events in a lengthy ongoing record were not highlighted and therefore not obvious to officers reviewing safeguarding provisions
d) Officers were unaware of the need to involve outside agencies in the ACCT review process, the range of options available to them to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews
e) The safer regimes meetings were not provided with all relevant information and were not used to their full effect. The minutes of the meetings were not fully recorded
f) A holistic approach was not taken to the safe management of the young person during ACCT reviews or Safer Regimes meetings when it was apparent that he was struggling with the regime and that interventions were not working
3. Conflict between Regimes
a) Officers did not always seek advice before placing the young person on report for tattooing when there was an indication in the ACCT documentation that adjudication awards would lead to a heighted risk of self-harm
b) There was a conflict between the use of a behaviour improvement plan and adjudications which was not recognised at the time
4. Early Release
a) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release
5.Cell entry
a) There appeared to be an inflexible approach to cell entry requiring the presence of three prison officers even though YOI was in patrol state and concerns were sufficient to require entry
Re: Healthcare at Cookham Wood
NB: the service provider has changed since the death of Alex Kelly. The new provider is in the process of determining the systems and procedures being put in place at Cookham Wood
1. Sharing of Information
a) Officers concerned with the management of the young person were not informed in terms of his non-compliance with medication and the potential effect of the failure to take the medication
2. Medication management
a) a)Medication was found stockpiled in the young person’s cell; staff dispensing medication had not ensured it had been taken when it was probably recorded as having been taken
b) b)Any failure to take medication was not sufficiently flagged for healthcare/prison staff to deal with the issue
3.Recording of information
a) Not all occasions when the young person was seen by the in-reach team were recorded on System One
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to verify medication ingestion before recording administration
Wider context from the report “Re: Secretary of State for Justice
Alex Kelly a vulnerable looked after child of 15 years with complex unresolved emotional issues and unmanaged mental health issues was sentenced to a Detention and Training Order to be served at a Young Offender’s Institution without the benefit of a forensic psychiatric assessment. Whilst I heard evidence from a psychiatrist associate of Cookham Wood YOI that the mental health in-reach team were able to address Alex’s mental health needs whilst in custody, I am aware of the deaths of a number of other children in custody who similarly had not had forensic psychiatric assessments and it is for this reason I am reporting the concern. Whilst hearing evidence in relation to lessons learned I heard from the Service Manager of Medway Youth Offending Team that they have now secured the services of a psychiatric mental health nurse to assist them in the effective management of the young people for whom they have responsibilities which I was told was proving effective and is to be continued.
Alex Kelly was under an ACCT between the 23rd December 2011 and 3rd January 2012 and 6th January 2012 until his death. During the operation of the ACCT there was a continued conflict between the ACCT process and disciplinary procedures; outside agencies and carers were not asked to contribute; specific acts by Alex were seen as obstructive/challenging behaviour rather than signs of distress or a means of communicating that he needed help (his foster carers who had not been asked to contribute had some experience of Alex using non-verbal methods of communication); the ACCT reviews tended to focus on addressing specific or recent behaviours rather than the reason for the behaviour; although Alex was frequently mentioned at weekly safer regimes multidisciplinary meetings, a holistic approach was never adopted as to how he could best be supported or whether the YOI could support his needs.
Re: Tower Hamlets
1. Allocation
a) Alex Kelly was without a named social worker for a period of two months at a time when he was in danger of being sent to custody and after he was sent to custody. Difficulties in allocation were not escalated to senior management
2. IT
a) Social workers did not transfer documentation including emails onto Framework in a timely manner or at all
b) There was no system in place for ensuring that urgent electronic communications were flagged/diverted when the recipient was absent from work
3. Custody
a) Social workers did not all appear to appreciate that their responsibilities as Corporate Parent included a role in a looked after child’s welfare whilst in custody
Re: Medway Youth Offending Team
1. Involvement with other agencies
a) Shortcomings in other agencies which affected the ability of the YOT to manage the young person were not brought to the attention of management
2. Placement within the Secure Estate
a) There were inconsistencies in recommendations as to placement in a STC/YOI which were not reconciled
b) Youth Offending Team keyworkers did not all appear to appreciate that their responsibilities included a role in the young person’s welfare whilst in custody
c) Members of the Youth Offending Team did not all appear to appreciate that the Youth Offending Team could initiate a transfer within the secure estate
3. Caseworker based at Cookham Wood YOI
a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person
b) Although involved in the ACCT reviews the caseworker was unaware of the range of options available to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews
c) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release
Re: Cookham Wood YOI
1. Communication with outside agencies
a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person
2. ACCT
a) Officers were inconsistent in the recording of significant events; entries being made in either the wing observation log, ACCT ongoing record or not at all
b) At least one officer did not appear to appreciate the importance of significant incidents/disclosures or report them
c) Significant events in a lengthy ongoing record were not highlighted and therefore not obvious to officers reviewing safeguarding provisions
d) Officers were unaware of the need to involve outside agencies in the ACCT review process, the range of options available to them to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews
e) The safer regimes meetings were not provided with all relevant information and were not used to their full effect. The minutes of the meetings were not fully recorded
f) A holistic approach was not taken to the safe management of the young person during ACCT reviews or Safer Regimes meetings when it was apparent that he was struggling with the regime and that interventions were not working
3. Conflict between Regimes
a) Officers did not always seek advice before placing the young person on report for tattooing when there was an indication in the ACCT documentation that adjudication awards would lead to a heighted risk of self-harm
b) There was a conflict between the use of a behaviour improvement plan and adjudications which was not recognised at the time
4. Early Release
a) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release
5.Cell entry
a) There appeared to be an inflexible approach to cell entry requiring the presence of three prison officers even though YOI was in patrol state and concerns were sufficient to require entry
Re: Healthcare at Cookham Wood
NB: the service provider has changed since the death of Alex Kelly. The new provider is in the process of determining the systems and procedures being put in place at Cookham Wood
1. Sharing of Information
a) Officers concerned with the management of the young person were not informed in terms of his non-compliance with medication and the potential effect of the failure to take the medication
2. Medication management
a) a)Medication was found stockpiled in the young person’s cell; staff dispensing medication had not ensured it had been taken when it was probably recorded as having been taken
b) b)Any failure to take medication was not sufficiently flagged for healthcare/prison staff to deal with the issue
3.Recording of information
a) Not all occasions when the young person was seen by the in-reach team were recorded on System One
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable 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 transfer documentation and emails onto Framework
Wider context from the report “Re: Secretary of State for Justice
Alex Kelly a vulnerable looked after child of 15 years with complex unresolved emotional issues and unmanaged mental health issues was sentenced to a Detention and Training Order to be served at a Young Offender’s Institution without the benefit of a forensic psychiatric assessment. Whilst I heard evidence from a psychiatrist associate of Cookham Wood YOI that the mental health in-reach team were able to address Alex’s mental health needs whilst in custody, I am aware of the deaths of a number of other children in custody who similarly had not had forensic psychiatric assessments and it is for this reason I am reporting the concern. Whilst hearing evidence in relation to lessons learned I heard from the Service Manager of Medway Youth Offending Team that they have now secured the services of a psychiatric mental health nurse to assist them in the effective management of the young people for whom they have responsibilities which I was told was proving effective and is to be continued.
Alex Kelly was under an ACCT between the 23rd December 2011 and 3rd January 2012 and 6th January 2012 until his death. During the operation of the ACCT there was a continued conflict between the ACCT process and disciplinary procedures; outside agencies and carers were not asked to contribute; specific acts by Alex were seen as obstructive/challenging behaviour rather than signs of distress or a means of communicating that he needed help (his foster carers who had not been asked to contribute had some experience of Alex using non-verbal methods of communication); the ACCT reviews tended to focus on addressing specific or recent behaviours rather than the reason for the behaviour; although Alex was frequently mentioned at weekly safer regimes multidisciplinary meetings, a holistic approach was never adopted as to how he could best be supported or whether the YOI could support his needs.
Re: Tower Hamlets
1. Allocation
a) Alex Kelly was without a named social worker for a period of two months at a time when he was in danger of being sent to custody and after he was sent to custody. Difficulties in allocation were not escalated to senior management
2. IT
a) Social workers did not transfer documentation including emails onto Framework in a timely manner or at all
b) There was no system in place for ensuring that urgent electronic communications were flagged/diverted when the recipient was absent from work
3. Custody
a) Social workers did not all appear to appreciate that their responsibilities as Corporate Parent included a role in a looked after child’s welfare whilst in custody
Re: Medway Youth Offending Team
1. Involvement with other agencies
a) Shortcomings in other agencies which affected the ability of the YOT to manage the young person were not brought to the attention of management
2. Placement within the Secure Estate
a) There were inconsistencies in recommendations as to placement in a STC/YOI which were not reconciled
b) Youth Offending Team keyworkers did not all appear to appreciate that their responsibilities included a role in the young person’s welfare whilst in custody
c) Members of the Youth Offending Team did not all appear to appreciate that the Youth Offending Team could initiate a transfer within the secure estate
3. Caseworker based at Cookham Wood YOI
a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person
b) Although involved in the ACCT reviews the caseworker was unaware of the range of options available to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews
c) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release
Re: Cookham Wood YOI
1. Communication with outside agencies
a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person
2. ACCT
a) Officers were inconsistent in the recording of significant events; entries being made in either the wing observation log, ACCT ongoing record or not at all
b) At least one officer did not appear to appreciate the importance of significant incidents/disclosures or report them
c) Significant events in a lengthy ongoing record were not highlighted and therefore not obvious to officers reviewing safeguarding provisions
d) Officers were unaware of the need to involve outside agencies in the ACCT review process, the range of options available to them to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews
e) The safer regimes meetings were not provided with all relevant information and were not used to their full effect. The minutes of the meetings were not fully recorded
f) A holistic approach was not taken to the safe management of the young person during ACCT reviews or Safer Regimes meetings when it was apparent that he was struggling with the regime and that interventions were not working
3. Conflict between Regimes
a) Officers did not always seek advice before placing the young person on report for tattooing when there was an indication in the ACCT documentation that adjudication awards would lead to a heighted risk of self-harm
b) There was a conflict between the use of a behaviour improvement plan and adjudications which was not recognised at the time
4. Early Release
a) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release
5.Cell entry
a) There appeared to be an inflexible approach to cell entry requiring the presence of three prison officers even though YOI was in patrol state and concerns were sufficient to require entry
Re: Healthcare at Cookham Wood
NB: the service provider has changed since the death of Alex Kelly. The new provider is in the process of determining the systems and procedures being put in place at Cookham Wood
1. Sharing of Information
a) Officers concerned with the management of the young person were not informed in terms of his non-compliance with medication and the potential effect of the failure to take the medication
2. Medication management
a) a)Medication was found stockpiled in the young person’s cell; staff dispensing medication had not ensured it had been taken when it was probably recorded as having been taken
b) b)Any failure to take medication was not sufficiently flagged for healthcare/prison staff to deal with the issue
3.Recording of information
a) Not all occasions when the young person was seen by the in-reach team were recorded on System One
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise distress communicated through behaviour
Wider context from the report “Re: Secretary of State for Justice
Alex Kelly a vulnerable looked after child of 15 years with complex unresolved emotional issues and unmanaged mental health issues was sentenced to a Detention and Training Order to be served at a Young Offender’s Institution without the benefit of a forensic psychiatric assessment. Whilst I heard evidence from a psychiatrist associate of Cookham Wood YOI that the mental health in-reach team were able to address Alex’s mental health needs whilst in custody, I am aware of the deaths of a number of other children in custody who similarly had not had forensic psychiatric assessments and it is for this reason I am reporting the concern. Whilst hearing evidence in relation to lessons learned I heard from the Service Manager of Medway Youth Offending Team that they have now secured the services of a psychiatric mental health nurse to assist them in the effective management of the young people for whom they have responsibilities which I was told was proving effective and is to be continued.
Alex Kelly was under an ACCT between the 23rd December 2011 and 3rd January 2012 and 6th January 2012 until his death. During the operation of the ACCT there was a continued conflict between the ACCT process and disciplinary procedures; outside agencies and carers were not asked to contribute; specific acts by Alex were seen as obstructive/challenging behaviour rather than signs of distress or a means of communicating that he needed help (his foster carers who had not been asked to contribute had some experience of Alex using non-verbal methods of communication); the ACCT reviews tended to focus on addressing specific or recent behaviours rather than the reason for the behaviour; although Alex was frequently mentioned at weekly safer regimes multidisciplinary meetings, a holistic approach was never adopted as to how he could best be supported or whether the YOI could support his needs.
Re: Tower Hamlets
1. Allocation
a) Alex Kelly was without a named social worker for a period of two months at a time when he was in danger of being sent to custody and after he was sent to custody. Difficulties in allocation were not escalated to senior management
2. IT
a) Social workers did not transfer documentation including emails onto Framework in a timely manner or at all
b) There was no system in place for ensuring that urgent electronic communications were flagged/diverted when the recipient was absent from work
3. Custody
a) Social workers did not all appear to appreciate that their responsibilities as Corporate Parent included a role in a looked after child’s welfare whilst in custody
Re: Medway Youth Offending Team
1. Involvement with other agencies
a) Shortcomings in other agencies which affected the ability of the YOT to manage the young person were not brought to the attention of management
2. Placement within the Secure Estate
a) There were inconsistencies in recommendations as to placement in a STC/YOI which were not reconciled
b) Youth Offending Team keyworkers did not all appear to appreciate that their responsibilities included a role in the young person’s welfare whilst in custody
c) Members of the Youth Offending Team did not all appear to appreciate that the Youth Offending Team could initiate a transfer within the secure estate
3. Caseworker based at Cookham Wood YOI
a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person
b) Although involved in the ACCT reviews the caseworker was unaware of the range of options available to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews
c) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release
Re: Cookham Wood YOI
1. Communication with outside agencies
a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person
2. ACCT
a) Officers were inconsistent in the recording of significant events; entries being made in either the wing observation log, ACCT ongoing record or not at all
b) At least one officer did not appear to appreciate the importance of significant incidents/disclosures or report them
c) Significant events in a lengthy ongoing record were not highlighted and therefore not obvious to officers reviewing safeguarding provisions
d) Officers were unaware of the need to involve outside agencies in the ACCT review process, the range of options available to them to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews
e) The safer regimes meetings were not provided with all relevant information and were not used to their full effect. The minutes of the meetings were not fully recorded
f) A holistic approach was not taken to the safe management of the young person during ACCT reviews or Safer Regimes meetings when it was apparent that he was struggling with the regime and that interventions were not working
3. Conflict between Regimes
a) Officers did not always seek advice before placing the young person on report for tattooing when there was an indication in the ACCT documentation that adjudication awards would lead to a heighted risk of self-harm
b) There was a conflict between the use of a behaviour improvement plan and adjudications which was not recognised at the time
4. Early Release
a) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release
5.Cell entry
a) There appeared to be an inflexible approach to cell entry requiring the presence of three prison officers even though YOI was in patrol state and concerns were sufficient to require entry
Re: Healthcare at Cookham Wood
NB: the service provider has changed since the death of Alex Kelly. The new provider is in the process of determining the systems and procedures being put in place at Cookham Wood
1. Sharing of Information
a) Officers concerned with the management of the young person were not informed in terms of his non-compliance with medication and the potential effect of the failure to take the medication
2. Medication management
a) a)Medication was found stockpiled in the young person’s cell; staff dispensing medication had not ensured it had been taken when it was probably recorded as having been taken
b) b)Any failure to take medication was not sufficiently flagged for healthcare/prison staff to deal with the issue
3.Recording of information
a) Not all occasions when the young person was seen by the in-reach team were recorded on System One
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise conflict between behaviour plans and adjudications
Wider context from the report “Re: Secretary of State for Justice
Alex Kelly a vulnerable looked after child of 15 years with complex unresolved emotional issues and unmanaged mental health issues was sentenced to a Detention and Training Order to be served at a Young Offender’s Institution without the benefit of a forensic psychiatric assessment. Whilst I heard evidence from a psychiatrist associate of Cookham Wood YOI that the mental health in-reach team were able to address Alex’s mental health needs whilst in custody, I am aware of the deaths of a number of other children in custody who similarly had not had forensic psychiatric assessments and it is for this reason I am reporting the concern. Whilst hearing evidence in relation to lessons learned I heard from the Service Manager of Medway Youth Offending Team that they have now secured the services of a psychiatric mental health nurse to assist them in the effective management of the young people for whom they have responsibilities which I was told was proving effective and is to be continued.
Alex Kelly was under an ACCT between the 23rd December 2011 and 3rd January 2012 and 6th January 2012 until his death. During the operation of the ACCT there was a continued conflict between the ACCT process and disciplinary procedures; outside agencies and carers were not asked to contribute; specific acts by Alex were seen as obstructive/challenging behaviour rather than signs of distress or a means of communicating that he needed help (his foster carers who had not been asked to contribute had some experience of Alex using non-verbal methods of communication); the ACCT reviews tended to focus on addressing specific or recent behaviours rather than the reason for the behaviour; although Alex was frequently mentioned at weekly safer regimes multidisciplinary meetings, a holistic approach was never adopted as to how he could best be supported or whether the YOI could support his needs.
Re: Tower Hamlets
1. Allocation
a) Alex Kelly was without a named social worker for a period of two months at a time when he was in danger of being sent to custody and after he was sent to custody. Difficulties in allocation were not escalated to senior management
2. IT
a) Social workers did not transfer documentation including emails onto Framework in a timely manner or at all
b) There was no system in place for ensuring that urgent electronic communications were flagged/diverted when the recipient was absent from work
3. Custody
a) Social workers did not all appear to appreciate that their responsibilities as Corporate Parent included a role in a looked after child’s welfare whilst in custody
Re: Medway Youth Offending Team
1. Involvement with other agencies
a) Shortcomings in other agencies which affected the ability of the YOT to manage the young person were not brought to the attention of management
2. Placement within the Secure Estate
a) There were inconsistencies in recommendations as to placement in a STC/YOI which were not reconciled
b) Youth Offending Team keyworkers did not all appear to appreciate that their responsibilities included a role in the young person’s welfare whilst in custody
c) Members of the Youth Offending Team did not all appear to appreciate that the Youth Offending Team could initiate a transfer within the secure estate
3. Caseworker based at Cookham Wood YOI
a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person
b) Although involved in the ACCT reviews the caseworker was unaware of the range of options available to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews
c) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release
Re: Cookham Wood YOI
1. Communication with outside agencies
a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person
2. ACCT
a) Officers were inconsistent in the recording of significant events; entries being made in either the wing observation log, ACCT ongoing record or not at all
b) At least one officer did not appear to appreciate the importance of significant incidents/disclosures or report them
c) Significant events in a lengthy ongoing record were not highlighted and therefore not obvious to officers reviewing safeguarding provisions
d) Officers were unaware of the need to involve outside agencies in the ACCT review process, the range of options available to them to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews
e) The safer regimes meetings were not provided with all relevant information and were not used to their full effect. The minutes of the meetings were not fully recorded
f) A holistic approach was not taken to the safe management of the young person during ACCT reviews or Safer Regimes meetings when it was apparent that he was struggling with the regime and that interventions were not working
3. Conflict between Regimes
a) Officers did not always seek advice before placing the young person on report for tattooing when there was an indication in the ACCT documentation that adjudication awards would lead to a heighted risk of self-harm
b) There was a conflict between the use of a behaviour improvement plan and adjudications which was not recognised at the time
4. Early Release
a) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release
5.Cell entry
a) There appeared to be an inflexible approach to cell entry requiring the presence of three prison officers even though YOI was in patrol state and concerns were sufficient to require entry
Re: Healthcare at Cookham Wood
NB: the service provider has changed since the death of Alex Kelly. The new provider is in the process of determining the systems and procedures being put in place at Cookham Wood
1. Sharing of Information
a) Officers concerned with the management of the young person were not informed in terms of his non-compliance with medication and the potential effect of the failure to take the medication
2. Medication management
a) a)Medication was found stockpiled in the young person’s cell; staff dispensing medication had not ensured it had been taken when it was probably recorded as having been taken
b) b)Any failure to take medication was not sufficiently flagged for healthcare/prison staff to deal with the issue
3.Recording of information
a) Not all occasions when the young person was seen by the in-reach team were recorded on System One
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable 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 YOT keyworkers to understand custodial welfare responsibilities
Wider context from the report “Re: Secretary of State for Justice
Alex Kelly a vulnerable looked after child of 15 years with complex unresolved emotional issues and unmanaged mental health issues was sentenced to a Detention and Training Order to be served at a Young Offender’s Institution without the benefit of a forensic psychiatric assessment. Whilst I heard evidence from a psychiatrist associate of Cookham Wood YOI that the mental health in-reach team were able to address Alex’s mental health needs whilst in custody, I am aware of the deaths of a number of other children in custody who similarly had not had forensic psychiatric assessments and it is for this reason I am reporting the concern. Whilst hearing evidence in relation to lessons learned I heard from the Service Manager of Medway Youth Offending Team that they have now secured the services of a psychiatric mental health nurse to assist them in the effective management of the young people for whom they have responsibilities which I was told was proving effective and is to be continued.
Alex Kelly was under an ACCT between the 23rd December 2011 and 3rd January 2012 and 6th January 2012 until his death. During the operation of the ACCT there was a continued conflict between the ACCT process and disciplinary procedures; outside agencies and carers were not asked to contribute; specific acts by Alex were seen as obstructive/challenging behaviour rather than signs of distress or a means of communicating that he needed help (his foster carers who had not been asked to contribute had some experience of Alex using non-verbal methods of communication); the ACCT reviews tended to focus on addressing specific or recent behaviours rather than the reason for the behaviour; although Alex was frequently mentioned at weekly safer regimes multidisciplinary meetings, a holistic approach was never adopted as to how he could best be supported or whether the YOI could support his needs.
Re: Tower Hamlets
1. Allocation
a) Alex Kelly was without a named social worker for a period of two months at a time when he was in danger of being sent to custody and after he was sent to custody. Difficulties in allocation were not escalated to senior management
2. IT
a) Social workers did not transfer documentation including emails onto Framework in a timely manner or at all
b) There was no system in place for ensuring that urgent electronic communications were flagged/diverted when the recipient was absent from work
3. Custody
a) Social workers did not all appear to appreciate that their responsibilities as Corporate Parent included a role in a looked after child’s welfare whilst in custody
Re: Medway Youth Offending Team
1. Involvement with other agencies
a) Shortcomings in other agencies which affected the ability of the YOT to manage the young person were not brought to the attention of management
2. Placement within the Secure Estate
a) There were inconsistencies in recommendations as to placement in a STC/YOI which were not reconciled
b) Youth Offending Team keyworkers did not all appear to appreciate that their responsibilities included a role in the young person’s welfare whilst in custody
c) Members of the Youth Offending Team did not all appear to appreciate that the Youth Offending Team could initiate a transfer within the secure estate
3. Caseworker based at Cookham Wood YOI
a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person
b) Although involved in the ACCT reviews the caseworker was unaware of the range of options available to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews
c) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release
Re: Cookham Wood YOI
1. Communication with outside agencies
a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person
2. ACCT
a) Officers were inconsistent in the recording of significant events; entries being made in either the wing observation log, ACCT ongoing record or not at all
b) At least one officer did not appear to appreciate the importance of significant incidents/disclosures or report them
c) Significant events in a lengthy ongoing record were not highlighted and therefore not obvious to officers reviewing safeguarding provisions
d) Officers were unaware of the need to involve outside agencies in the ACCT review process, the range of options available to them to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews
e) The safer regimes meetings were not provided with all relevant information and were not used to their full effect. The minutes of the meetings were not fully recorded
f) A holistic approach was not taken to the safe management of the young person during ACCT reviews or Safer Regimes meetings when it was apparent that he was struggling with the regime and that interventions were not working
3. Conflict between Regimes
a) Officers did not always seek advice before placing the young person on report for tattooing when there was an indication in the ACCT documentation that adjudication awards would lead to a heighted risk of self-harm
b) There was a conflict between the use of a behaviour improvement plan and adjudications which was not recognised at the time
4. Early Release
a) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release
5.Cell entry
a) There appeared to be an inflexible approach to cell entry requiring the presence of three prison officers even though YOI was in patrol state and concerns were sufficient to require entry
Re: Healthcare at Cookham Wood
NB: the service provider has changed since the death of Alex Kelly. The new provider is in the process of determining the systems and procedures being put in place at Cookham Wood
1. Sharing of Information
a) Officers concerned with the management of the young person were not informed in terms of his non-compliance with medication and the potential effect of the failure to take the medication
2. Medication management
a) a)Medication was found stockpiled in the young person’s cell; staff dispensing medication had not ensured it had been taken when it was probably recorded as having been taken
b) b)Any failure to take medication was not sufficiently flagged for healthcare/prison staff to deal with the issue
3.Recording of information
a) Not all occasions when the young person was seen by the in-reach team were recorded on System One
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to use holistic safe-management planning when interventions are ineffective
Wider context from the report “Re: Secretary of State for Justice
Alex Kelly a vulnerable looked after child of 15 years with complex unresolved emotional issues and unmanaged mental health issues was sentenced to a Detention and Training Order to be served at a Young Offender’s Institution without the benefit of a forensic psychiatric assessment. Whilst I heard evidence from a psychiatrist associate of Cookham Wood YOI that the mental health in-reach team were able to address Alex’s mental health needs whilst in custody, I am aware of the deaths of a number of other children in custody who similarly had not had forensic psychiatric assessments and it is for this reason I am reporting the concern. Whilst hearing evidence in relation to lessons learned I heard from the Service Manager of Medway Youth Offending Team that they have now secured the services of a psychiatric mental health nurse to assist them in the effective management of the young people for whom they have responsibilities which I was told was proving effective and is to be continued.
Alex Kelly was under an ACCT between the 23rd December 2011 and 3rd January 2012 and 6th January 2012 until his death. During the operation of the ACCT there was a continued conflict between the ACCT process and disciplinary procedures; outside agencies and carers were not asked to contribute; specific acts by Alex were seen as obstructive/challenging behaviour rather than signs of distress or a means of communicating that he needed help (his foster carers who had not been asked to contribute had some experience of Alex using non-verbal methods of communication); the ACCT reviews tended to focus on addressing specific or recent behaviours rather than the reason for the behaviour; although Alex was frequently mentioned at weekly safer regimes multidisciplinary meetings, a holistic approach was never adopted as to how he could best be supported or whether the YOI could support his needs.
Re: Tower Hamlets
1. Allocation
a) Alex Kelly was without a named social worker for a period of two months at a time when he was in danger of being sent to custody and after he was sent to custody. Difficulties in allocation were not escalated to senior management
2. IT
a) Social workers did not transfer documentation including emails onto Framework in a timely manner or at all
b) There was no system in place for ensuring that urgent electronic communications were flagged/diverted when the recipient was absent from work
3. Custody
a) Social workers did not all appear to appreciate that their responsibilities as Corporate Parent included a role in a looked after child’s welfare whilst in custody
Re: Medway Youth Offending Team
1. Involvement with other agencies
a) Shortcomings in other agencies which affected the ability of the YOT to manage the young person were not brought to the attention of management
2. Placement within the Secure Estate
a) There were inconsistencies in recommendations as to placement in a STC/YOI which were not reconciled
b) Youth Offending Team keyworkers did not all appear to appreciate that their responsibilities included a role in the young person’s welfare whilst in custody
c) Members of the Youth Offending Team did not all appear to appreciate that the Youth Offending Team could initiate a transfer within the secure estate
3. Caseworker based at Cookham Wood YOI
a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person
b) Although involved in the ACCT reviews the caseworker was unaware of the range of options available to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews
c) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release
Re: Cookham Wood YOI
1. Communication with outside agencies
a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person
2. ACCT
a) Officers were inconsistent in the recording of significant events; entries being made in either the wing observation log, ACCT ongoing record or not at all
b) At least one officer did not appear to appreciate the importance of significant incidents/disclosures or report them
c) Significant events in a lengthy ongoing record were not highlighted and therefore not obvious to officers reviewing safeguarding provisions
d) Officers were unaware of the need to involve outside agencies in the ACCT review process, the range of options available to them to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews
e) The safer regimes meetings were not provided with all relevant information and were not used to their full effect. The minutes of the meetings were not fully recorded
f) A holistic approach was not taken to the safe management of the young person during ACCT reviews or Safer Regimes meetings when it was apparent that he was struggling with the regime and that interventions were not working
3. Conflict between Regimes
a) Officers did not always seek advice before placing the young person on report for tattooing when there was an indication in the ACCT documentation that adjudication awards would lead to a heighted risk of self-harm
b) There was a conflict between the use of a behaviour improvement plan and adjudications which was not recognised at the time
4. Early Release
a) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release
5.Cell entry
a) There appeared to be an inflexible approach to cell entry requiring the presence of three prison officers even though YOI was in patrol state and concerns were sufficient to require entry
Re: Healthcare at Cookham Wood
NB: the service provider has changed since the death of Alex Kelly. The new provider is in the process of determining the systems and procedures being put in place at Cookham Wood
1. Sharing of Information
a) Officers concerned with the management of the young person were not informed in terms of his non-compliance with medication and the potential effect of the failure to take the medication
2. Medication management
a) a)Medication was found stockpiled in the young person’s cell; staff dispensing medication had not ensured it had been taken when it was probably recorded as having been taken
b) b)Any failure to take medication was not sufficiently flagged for healthcare/prison staff to deal with the issue
3.Recording of information
a) Not all occasions when the young person was seen by the in-reach team were recorded on System One
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Inflexible cell-entry requirements during urgent safeguarding concerns
Wider context from the report “Re: Secretary of State for Justice
Alex Kelly a vulnerable looked after child of 15 years with complex unresolved emotional issues and unmanaged mental health issues was sentenced to a Detention and Training Order to be served at a Young Offender’s Institution without the benefit of a forensic psychiatric assessment. Whilst I heard evidence from a psychiatrist associate of Cookham Wood YOI that the mental health in-reach team were able to address Alex’s mental health needs whilst in custody, I am aware of the deaths of a number of other children in custody who similarly had not had forensic psychiatric assessments and it is for this reason I am reporting the concern. Whilst hearing evidence in relation to lessons learned I heard from the Service Manager of Medway Youth Offending Team that they have now secured the services of a psychiatric mental health nurse to assist them in the effective management of the young people for whom they have responsibilities which I was told was proving effective and is to be continued.
Alex Kelly was under an ACCT between the 23rd December 2011 and 3rd January 2012 and 6th January 2012 until his death. During the operation of the ACCT there was a continued conflict between the ACCT process and disciplinary procedures; outside agencies and carers were not asked to contribute; specific acts by Alex were seen as obstructive/challenging behaviour rather than signs of distress or a means of communicating that he needed help (his foster carers who had not been asked to contribute had some experience of Alex using non-verbal methods of communication); the ACCT reviews tended to focus on addressing specific or recent behaviours rather than the reason for the behaviour; although Alex was frequently mentioned at weekly safer regimes multidisciplinary meetings, a holistic approach was never adopted as to how he could best be supported or whether the YOI could support his needs.
Re: Tower Hamlets
1. Allocation
a) Alex Kelly was without a named social worker for a period of two months at a time when he was in danger of being sent to custody and after he was sent to custody. Difficulties in allocation were not escalated to senior management
2. IT
a) Social workers did not transfer documentation including emails onto Framework in a timely manner or at all
b) There was no system in place for ensuring that urgent electronic communications were flagged/diverted when the recipient was absent from work
3. Custody
a) Social workers did not all appear to appreciate that their responsibilities as Corporate Parent included a role in a looked after child’s welfare whilst in custody
Re: Medway Youth Offending Team
1. Involvement with other agencies
a) Shortcomings in other agencies which affected the ability of the YOT to manage the young person were not brought to the attention of management
2. Placement within the Secure Estate
a) There were inconsistencies in recommendations as to placement in a STC/YOI which were not reconciled
b) Youth Offending Team keyworkers did not all appear to appreciate that their responsibilities included a role in the young person’s welfare whilst in custody
c) Members of the Youth Offending Team did not all appear to appreciate that the Youth Offending Team could initiate a transfer within the secure estate
3. Caseworker based at Cookham Wood YOI
a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person
b) Although involved in the ACCT reviews the caseworker was unaware of the range of options available to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews
c) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release
Re: Cookham Wood YOI
1. Communication with outside agencies
a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person
2. ACCT
a) Officers were inconsistent in the recording of significant events; entries being made in either the wing observation log, ACCT ongoing record or not at all
b) At least one officer did not appear to appreciate the importance of significant incidents/disclosures or report them
c) Significant events in a lengthy ongoing record were not highlighted and therefore not obvious to officers reviewing safeguarding provisions
d) Officers were unaware of the need to involve outside agencies in the ACCT review process, the range of options available to them to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews
e) The safer regimes meetings were not provided with all relevant information and were not used to their full effect. The minutes of the meetings were not fully recorded
f) A holistic approach was not taken to the safe management of the young person during ACCT reviews or Safer Regimes meetings when it was apparent that he was struggling with the regime and that interventions were not working
3. Conflict between Regimes
a) Officers did not always seek advice before placing the young person on report for tattooing when there was an indication in the ACCT documentation that adjudication awards would lead to a heighted risk of self-harm
b) There was a conflict between the use of a behaviour improvement plan and adjudications which was not recognised at the time
4. Early Release
a) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release
5.Cell entry
a) There appeared to be an inflexible approach to cell entry requiring the presence of three prison officers even though YOI was in patrol state and concerns were sufficient to require entry
Re: Healthcare at Cookham Wood
NB: the service provider has changed since the death of Alex Kelly. The new provider is in the process of determining the systems and procedures being put in place at Cookham Wood
1. Sharing of Information
a) Officers concerned with the management of the young person were not informed in terms of his non-compliance with medication and the potential effect of the failure to take the medication
2. Medication management
a) a)Medication was found stockpiled in the young person’s cell; staff dispensing medication had not ensured it had been taken when it was probably recorded as having been taken
b) b)Any failure to take medication was not sufficiently flagged for healthcare/prison staff to deal with the issue
3.Recording of information
a) Not all occasions when the young person was seen by the in-reach team were recorded on System One
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 forensic psychiatric assessment before custodial placement
Wider context from the report “Re: Secretary of State for Justice
Alex Kelly a vulnerable looked after child of 15 years with complex unresolved emotional issues and unmanaged mental health issues was sentenced to a Detention and Training Order to be served at a Young Offender’s Institution without the benefit of a forensic psychiatric assessment . Whilst I heard evidence from a psychiatrist associate of Cookham Wood YOI that the mental health in-reach team were able to address Alex’s mental health needs whilst in custody, I am aware of the deaths of a number of other children in custody who similarly had not had forensic psychiatric assessments and it is for this reason I am reporting the concern. Whilst hearing evidence in relation to lessons learned I heard from the Service Manager of Medway Youth Offending Team that they have now secured the services of a psychiatric mental health nurse to assist them in the effective management of the young people for whom they have responsibilities which I was told was proving effective and is to be continued.
Alex Kelly was under an ACCT between the 23rd December 2011 and 3rd January 2012 and 6th January 2012 until his death. During the operation of the ACCT there was a continued conflict between the ACCT process and disciplinary procedures; outside agencies and carers were not asked to contribute; specific acts by Alex were seen as obstructive/challenging behaviour rather than signs of distress or a means of communicating that he needed help (his foster carers who had not been asked to contribute had some experience of Alex using non-verbal methods of communication); the ACCT reviews tended to focus on addressing specific or recent behaviours rather than the reason for the behaviour; although Alex was frequently mentioned at weekly safer regimes multidisciplinary meetings, a holistic approach was never adopted as to how he could best be supported or whether the YOI could support his needs.
Re: Tower Hamlets
1. Allocation
a) Alex Kelly was without a named social worker for a period of two months at a time when he was in danger of being sent to custody and after he was sent to custody. Difficulties in allocation were not escalated to senior management
2. IT
a) Social workers did not transfer documentation including emails onto Framework in a timely manner or at all
b) There was no system in place for ensuring that urgent electronic communications were flagged/diverted when the recipient was absent from work
3. Custody
a) Social workers did not all appear to appreciate that their responsibilities as Corporate Parent included a role in a looked after child’s welfare whilst in custody
Re: Medway Youth Offending Team
1. Involvement with other agencies
a) Shortcomings in other agencies which affected the ability of the YOT to manage the young person were not brought to the attention of management
2. Placement within the Secure Estate
a) There were inconsistencies in recommendations as to placement in a STC/YOI which were not reconciled
b) Youth Offending Team keyworkers did not all appear to appreciate that their responsibilities included a role in the young person’s welfare whilst in custody
c) Members of the Youth Offending Team did not all appear to appreciate that the Youth Offending Team could initiate a transfer within the secure estate
3. Caseworker based at Cookham Wood YOI
a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person
b) Although involved in the ACCT reviews the caseworker was unaware of the range of options available to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews
c) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release
Re: Cookham Wood YOI
1. Communication with outside agencies
a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person
2. ACCT
a) Officers were inconsistent in the recording of significant events; entries being made in either the wing observation log, ACCT ongoing record or not at all
b) At least one officer did not appear to appreciate the importance of significant incidents/disclosures or report them
c) Significant events in a lengthy ongoing record were not highlighted and therefore not obvious to officers reviewing safeguarding provisions
d) Officers were unaware of the need to involve outside agencies in the ACCT review process, the range of options available to them to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews
e) The safer regimes meetings were not provided with all relevant information and were not used to their full effect. The minutes of the meetings were not fully recorded
f) A holistic approach was not taken to the safe management of the young person during ACCT reviews or Safer Regimes meetings when it was apparent that he was struggling with the regime and that interventions were not working
3. Conflict between Regimes
a) Officers did not always seek advice before placing the young person on report for tattooing when there was an indication in the ACCT documentation that adjudication awards would lead to a heighted risk of self-harm
b) There was a conflict between the use of a behaviour improvement plan and adjudications which was not recognised at the time
4. Early Release
a) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release
5.Cell entry
a) There appeared to be an inflexible approach to cell entry requiring the presence of three prison officers even though YOI was in patrol state and concerns were sufficient to require entry
Re: Healthcare at Cookham Wood
NB: the service provider has changed since the death of Alex Kelly. The new provider is in the process of determining the systems and procedures being put in place at Cookham Wood
1. Sharing of Information
a) Officers concerned with the management of the young person were not informed in terms of his non-compliance with medication and the potential effect of the failure to take the medication
2. Medication management
a) a)Medication was found stockpiled in the young person’s cell; staff dispensing medication had not ensured it had been taken when it was probably recorded as having been taken
b) b)Any failure to take medication was not sufficiently flagged for healthcare/prison staff to deal with the issue
3.Recording of information
a) Not all occasions when the young person was seen by the in-reach team were recorded on System One
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Conflict between ACCT and disciplinary procedures
Wider context from the report “Re: Secretary of State for Justice
Alex Kelly a vulnerable looked after child of 15 years with complex unresolved emotional issues and unmanaged mental health issues was sentenced to a Detention and Training Order to be served at a Young Offender’s Institution without the benefit of a forensic psychiatric assessment. Whilst I heard evidence from a psychiatrist associate of Cookham Wood YOI that the mental health in-reach team were able to address Alex’s mental health needs whilst in custody, I am aware of the deaths of a number of other children in custody who similarly had not had forensic psychiatric assessments and it is for this reason I am reporting the concern. Whilst hearing evidence in relation to lessons learned I heard from the Service Manager of Medway Youth Offending Team that they have now secured the services of a psychiatric mental health nurse to assist them in the effective management of the young people for whom they have responsibilities which I was told was proving effective and is to be continued.
Alex Kelly was under an ACCT between the 23rd December 2011 and 3rd January 2012 and 6th January 2012 until his death. During the operation of the ACCT there was a continued conflict between the ACCT process and disciplinary procedures ; outside agencies and carers were not asked to contribute; specific acts by Alex were seen as obstructive/challenging behaviour rather than signs of distress or a means of communicating that he needed help (his foster carers who had not been asked to contribute had some experience of Alex using non-verbal methods of communication); the ACCT reviews tended to focus on addressing specific or recent behaviours rather than the reason for the behaviour; although Alex was frequently mentioned at weekly safer regimes multidisciplinary meetings, a holistic approach was never adopted as to how he could best be supported or whether the YOI could support his needs.
Re: Tower Hamlets
1. Allocation
a) Alex Kelly was without a named social worker for a period of two months at a time when he was in danger of being sent to custody and after he was sent to custody. Difficulties in allocation were not escalated to senior management
2. IT
a) Social workers did not transfer documentation including emails onto Framework in a timely manner or at all
b) There was no system in place for ensuring that urgent electronic communications were flagged/diverted when the recipient was absent from work
3. Custody
a) Social workers did not all appear to appreciate that their responsibilities as Corporate Parent included a role in a looked after child’s welfare whilst in custody
Re: Medway Youth Offending Team
1. Involvement with other agencies
a) Shortcomings in other agencies which affected the ability of the YOT to manage the young person were not brought to the attention of management
2. Placement within the Secure Estate
a) There were inconsistencies in recommendations as to placement in a STC/YOI which were not reconciled
b) Youth Offending Team keyworkers did not all appear to appreciate that their responsibilities included a role in the young person’s welfare whilst in custody
c) Members of the Youth Offending Team did not all appear to appreciate that the Youth Offending Team could initiate a transfer within the secure estate
3. Caseworker based at Cookham Wood YOI
a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person
b) Although involved in the ACCT reviews the caseworker was unaware of the range of options available to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews
c) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release
Re: Cookham Wood YOI
1. Communication with outside agencies
a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person
2. ACCT
a) Officers were inconsistent in the recording of significant events; entries being made in either the wing observation log, ACCT ongoing record or not at all
b) At least one officer did not appear to appreciate the importance of significant incidents/disclosures or report them
c) Significant events in a lengthy ongoing record were not highlighted and therefore not obvious to officers reviewing safeguarding provisions
d) Officers were unaware of the need to involve outside agencies in the ACCT review process, the range of options available to them to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews
e) The safer regimes meetings were not provided with all relevant information and were not used to their full effect. The minutes of the meetings were not fully recorded
f) A holistic approach was not taken to the safe management of the young person during ACCT reviews or Safer Regimes meetings when it was apparent that he was struggling with the regime and that interventions were not working
3. Conflict between Regimes
a) Officers did not always seek advice before placing the young person on report for tattooing when there was an indication in the ACCT documentation that adjudication awards would lead to a heighted risk of self-harm
b) There was a conflict between the use of a behaviour improvement plan and adjudications which was not recognised at the time
4. Early Release
a) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release
5.Cell entry
a) There appeared to be an inflexible approach to cell entry requiring the presence of three prison officers even though YOI was in patrol state and concerns were sufficient to require entry
Re: Healthcare at Cookham Wood
NB: the service provider has changed since the death of Alex Kelly. The new provider is in the process of determining the systems and procedures being put in place at Cookham Wood
1. Sharing of Information
a) Officers concerned with the management of the young person were not informed in terms of his non-compliance with medication and the potential effect of the failure to take the medication
2. Medication management
a) a)Medication was found stockpiled in the young person’s cell; staff dispensing medication had not ensured it had been taken when it was probably recorded as having been taken
b) b)Any failure to take medication was not sufficiently flagged for healthcare/prison staff to deal with the issue
3.Recording of information
a) Not all occasions when the young person was seen by the in-reach team were recorded on System One
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 allocating a named social worker and escalating allocation difficulties
Wider context from the report “Re: Secretary of State for Justice
Alex Kelly a vulnerable looked after child of 15 years with complex unresolved emotional issues and unmanaged mental health issues was sentenced to a Detention and Training Order to be served at a Young Offender’s Institution without the benefit of a forensic psychiatric assessment. Whilst I heard evidence from a psychiatrist associate of Cookham Wood YOI that the mental health in-reach team were able to address Alex’s mental health needs whilst in custody, I am aware of the deaths of a number of other children in custody who similarly had not had forensic psychiatric assessments and it is for this reason I am reporting the concern. Whilst hearing evidence in relation to lessons learned I heard from the Service Manager of Medway Youth Offending Team that they have now secured the services of a psychiatric mental health nurse to assist them in the effective management of the young people for whom they have responsibilities which I was told was proving effective and is to be continued.
Alex Kelly was under an ACCT between the 23rd December 2011 and 3rd January 2012 and 6th January 2012 until his death. During the operation of the ACCT there was a continued conflict between the ACCT process and disciplinary procedures; outside agencies and carers were not asked to contribute; specific acts by Alex were seen as obstructive/challenging behaviour rather than signs of distress or a means of communicating that he needed help (his foster carers who had not been asked to contribute had some experience of Alex using non-verbal methods of communication); the ACCT reviews tended to focus on addressing specific or recent behaviours rather than the reason for the behaviour; although Alex was frequently mentioned at weekly safer regimes multidisciplinary meetings, a holistic approach was never adopted as to how he could best be supported or whether the YOI could support his needs.
Re: Tower Hamlets
1. Allocation
a) Alex Kelly was without a named social worker for a period of two months at a time when he was in danger of being sent to custody and after he was sent to custody. Difficulties in allocation were not escalated to senior management
2. IT
a) Social workers did not transfer documentation including emails onto Framework in a timely manner or at all
b) There was no system in place for ensuring that urgent electronic communications were flagged/diverted when the recipient was absent from work
3. Custody
a) Social workers did not all appear to appreciate that their responsibilities as Corporate Parent included a role in a looked after child’s welfare whilst in custody
Re: Medway Youth Offending Team
1. Involvement with other agencies
a) Shortcomings in other agencies which affected the ability of the YOT to manage the young person were not brought to the attention of management
2. Placement within the Secure Estate
a) There were inconsistencies in recommendations as to placement in a STC/YOI which were not reconciled
b) Youth Offending Team keyworkers did not all appear to appreciate that their responsibilities included a role in the young person’s welfare whilst in custody
c) Members of the Youth Offending Team did not all appear to appreciate that the Youth Offending Team could initiate a transfer within the secure estate
3. Caseworker based at Cookham Wood YOI
a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person
b) Although involved in the ACCT reviews the caseworker was unaware of the range of options available to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews
c) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release
Re: Cookham Wood YOI
1. Communication with outside agencies
a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person
2. ACCT
a) Officers were inconsistent in the recording of significant events; entries being made in either the wing observation log, ACCT ongoing record or not at all
b) At least one officer did not appear to appreciate the importance of significant incidents/disclosures or report them
c) Significant events in a lengthy ongoing record were not highlighted and therefore not obvious to officers reviewing safeguarding provisions
d) Officers were unaware of the need to involve outside agencies in the ACCT review process, the range of options available to them to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews
e) The safer regimes meetings were not provided with all relevant information and were not used to their full effect. The minutes of the meetings were not fully recorded
f) A holistic approach was not taken to the safe management of the young person during ACCT reviews or Safer Regimes meetings when it was apparent that he was struggling with the regime and that interventions were not working
3. Conflict between Regimes
a) Officers did not always seek advice before placing the young person on report for tattooing when there was an indication in the ACCT documentation that adjudication awards would lead to a heighted risk of self-harm
b) There was a conflict between the use of a behaviour improvement plan and adjudications which was not recognised at the time
4. Early Release
a) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release
5.Cell entry
a) There appeared to be an inflexible approach to cell entry requiring the presence of three prison officers even though YOI was in patrol state and concerns were sufficient to require entry
Re: Healthcare at Cookham Wood
NB: the service provider has changed since the death of Alex Kelly. The new provider is in the process of determining the systems and procedures being put in place at Cookham Wood
1. Sharing of Information
a) Officers concerned with the management of the young person were not informed in terms of his non-compliance with medication and the potential effect of the failure to take the medication
2. Medication management
a) a)Medication was found stockpiled in the young person’s cell; staff dispensing medication had not ensured it had been taken when it was probably recorded as having been taken
b) b)Any failure to take medication was not sufficiently flagged for healthcare/prison staff to deal with the issue
3.Recording of information
a) Not all occasions when the young person was seen by the in-reach team were recorded on System One
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 recording of mental-health in-reach contacts on System One
Wider context from the report “Re: Secretary of State for Justice
Alex Kelly a vulnerable looked after child of 15 years with complex unresolved emotional issues and unmanaged mental health issues was sentenced to a Detention and Training Order to be served at a Young Offender’s Institution without the benefit of a forensic psychiatric assessment. Whilst I heard evidence from a psychiatrist associate of Cookham Wood YOI that the mental health in-reach team were able to address Alex’s mental health needs whilst in custody, I am aware of the deaths of a number of other children in custody who similarly had not had forensic psychiatric assessments and it is for this reason I am reporting the concern. Whilst hearing evidence in relation to lessons learned I heard from the Service Manager of Medway Youth Offending Team that they have now secured the services of a psychiatric mental health nurse to assist them in the effective management of the young people for whom they have responsibilities which I was told was proving effective and is to be continued.
Alex Kelly was under an ACCT between the 23rd December 2011 and 3rd January 2012 and 6th January 2012 until his death. During the operation of the ACCT there was a continued conflict between the ACCT process and disciplinary procedures; outside agencies and carers were not asked to contribute; specific acts by Alex were seen as obstructive/challenging behaviour rather than signs of distress or a means of communicating that he needed help (his foster carers who had not been asked to contribute had some experience of Alex using non-verbal methods of communication); the ACCT reviews tended to focus on addressing specific or recent behaviours rather than the reason for the behaviour; although Alex was frequently mentioned at weekly safer regimes multidisciplinary meetings, a holistic approach was never adopted as to how he could best be supported or whether the YOI could support his needs.
Re: Tower Hamlets
1. Allocation
a) Alex Kelly was without a named social worker for a period of two months at a time when he was in danger of being sent to custody and after he was sent to custody. Difficulties in allocation were not escalated to senior management
2. IT
a) Social workers did not transfer documentation including emails onto Framework in a timely manner or at all
b) There was no system in place for ensuring that urgent electronic communications were flagged/diverted when the recipient was absent from work
3. Custody
a) Social workers did not all appear to appreciate that their responsibilities as Corporate Parent included a role in a looked after child’s welfare whilst in custody
Re: Medway Youth Offending Team
1. Involvement with other agencies
a) Shortcomings in other agencies which affected the ability of the YOT to manage the young person were not brought to the attention of management
2. Placement within the Secure Estate
a) There were inconsistencies in recommendations as to placement in a STC/YOI which were not reconciled
b) Youth Offending Team keyworkers did not all appear to appreciate that their responsibilities included a role in the young person’s welfare whilst in custody
c) Members of the Youth Offending Team did not all appear to appreciate that the Youth Offending Team could initiate a transfer within the secure estate
3. Caseworker based at Cookham Wood YOI
a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person
b) Although involved in the ACCT reviews the caseworker was unaware of the range of options available to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews
c) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release
Re: Cookham Wood YOI
1. Communication with outside agencies
a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person
2. ACCT
a) Officers were inconsistent in the recording of significant events; entries being made in either the wing observation log, ACCT ongoing record or not at all
b) At least one officer did not appear to appreciate the importance of significant incidents/disclosures or report them
c) Significant events in a lengthy ongoing record were not highlighted and therefore not obvious to officers reviewing safeguarding provisions
d) Officers were unaware of the need to involve outside agencies in the ACCT review process, the range of options available to them to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews
e) The safer regimes meetings were not provided with all relevant information and were not used to their full effect. The minutes of the meetings were not fully recorded
f) A holistic approach was not taken to the safe management of the young person during ACCT reviews or Safer Regimes meetings when it was apparent that he was struggling with the regime and that interventions were not working
3. Conflict between Regimes
a) Officers did not always seek advice before placing the young person on report for tattooing when there was an indication in the ACCT documentation that adjudication awards would lead to a heighted risk of self-harm
b) There was a conflict between the use of a behaviour improvement plan and adjudications which was not recognised at the time
4. Early Release
a) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release
5.Cell entry
a) There appeared to be an inflexible approach to cell entry requiring the presence of three prison officers even though YOI was in patrol state and concerns were sufficient to require entry
Re: Healthcare at Cookham Wood
NB: the service provider has changed since the death of Alex Kelly. The new provider is in the process of determining the systems and procedures being put in place at Cookham Wood
1. Sharing of Information
a) Officers concerned with the management of the young person were not informed in terms of his non-compliance with medication and the potential effect of the failure to take the medication
2. Medication management
a) a)Medication was found stockpiled in the young person’s cell; staff dispensing medication had not ensured it had been taken when it was probably recorded as having been taken
b) b)Any failure to take medication was not sufficiently flagged for healthcare/prison staff to deal with the issue
3.Recording of information
a) Not all occasions when the young person was seen by the in-reach team were recorded on System One
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to share medication non-compliance and its potential effects
Wider context from the report “Re: Secretary of State for Justice
Alex Kelly a vulnerable looked after child of 15 years with complex unresolved emotional issues and unmanaged mental health issues was sentenced to a Detention and Training Order to be served at a Young Offender’s Institution without the benefit of a forensic psychiatric assessment. Whilst I heard evidence from a psychiatrist associate of Cookham Wood YOI that the mental health in-reach team were able to address Alex’s mental health needs whilst in custody, I am aware of the deaths of a number of other children in custody who similarly had not had forensic psychiatric assessments and it is for this reason I am reporting the concern. Whilst hearing evidence in relation to lessons learned I heard from the Service Manager of Medway Youth Offending Team that they have now secured the services of a psychiatric mental health nurse to assist them in the effective management of the young people for whom they have responsibilities which I was told was proving effective and is to be continued.
Alex Kelly was under an ACCT between the 23rd December 2011 and 3rd January 2012 and 6th January 2012 until his death. During the operation of the ACCT there was a continued conflict between the ACCT process and disciplinary procedures; outside agencies and carers were not asked to contribute; specific acts by Alex were seen as obstructive/challenging behaviour rather than signs of distress or a means of communicating that he needed help (his foster carers who had not been asked to contribute had some experience of Alex using non-verbal methods of communication); the ACCT reviews tended to focus on addressing specific or recent behaviours rather than the reason for the behaviour; although Alex was frequently mentioned at weekly safer regimes multidisciplinary meetings, a holistic approach was never adopted as to how he could best be supported or whether the YOI could support his needs.
Re: Tower Hamlets
1. Allocation
a) Alex Kelly was without a named social worker for a period of two months at a time when he was in danger of being sent to custody and after he was sent to custody. Difficulties in allocation were not escalated to senior management
2. IT
a) Social workers did not transfer documentation including emails onto Framework in a timely manner or at all
b) There was no system in place for ensuring that urgent electronic communications were flagged/diverted when the recipient was absent from work
3. Custody
a) Social workers did not all appear to appreciate that their responsibilities as Corporate Parent included a role in a looked after child’s welfare whilst in custody
Re: Medway Youth Offending Team
1. Involvement with other agencies
a) Shortcomings in other agencies which affected the ability of the YOT to manage the young person were not brought to the attention of management
2. Placement within the Secure Estate
a) There were inconsistencies in recommendations as to placement in a STC/YOI which were not reconciled
b) Youth Offending Team keyworkers did not all appear to appreciate that their responsibilities included a role in the young person’s welfare whilst in custody
c) Members of the Youth Offending Team did not all appear to appreciate that the Youth Offending Team could initiate a transfer within the secure estate
3. Caseworker based at Cookham Wood YOI
a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person
b) Although involved in the ACCT reviews the caseworker was unaware of the range of options available to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews
c) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release
Re: Cookham Wood YOI
1. Communication with outside agencies
a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person
2. ACCT
a) Officers were inconsistent in the recording of significant events; entries being made in either the wing observation log, ACCT ongoing record or not at all
b) At least one officer did not appear to appreciate the importance of significant incidents/disclosures or report them
c) Significant events in a lengthy ongoing record were not highlighted and therefore not obvious to officers reviewing safeguarding provisions
d) Officers were unaware of the need to involve outside agencies in the ACCT review process, the range of options available to them to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews
e) The safer regimes meetings were not provided with all relevant information and were not used to their full effect. The minutes of the meetings were not fully recorded
f) A holistic approach was not taken to the safe management of the young person during ACCT reviews or Safer Regimes meetings when it was apparent that he was struggling with the regime and that interventions were not working
3. Conflict between Regimes
a) Officers did not always seek advice before placing the young person on report for tattooing when there was an indication in the ACCT documentation that adjudication awards would lead to a heighted risk of self-harm
b) There was a conflict between the use of a behaviour improvement plan and adjudications which was not recognised at the time
4. Early Release
a) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release
5.Cell entry
a) There appeared to be an inflexible approach to cell entry requiring the presence of three prison officers even though YOI was in patrol state and concerns were sufficient to require entry
Re: Healthcare at Cookham Wood
NB: the service provider has changed since the death of Alex Kelly. The new provider is in the process of determining the systems and procedures being put in place at Cookham Wood
1. Sharing of Information
a) Officers concerned with the management of the young person were not informed in terms of his non-compliance with medication and the potential effect of the failure to take the medication
2. Medication management
a) a)Medication was found stockpiled in the young person’s cell; staff dispensing medication had not ensured it had been taken when it was probably recorded as having been taken
b) b)Any failure to take medication was not sufficiently flagged for healthcare/prison staff to deal with the issue
3.Recording of information
a) Not all occasions when the young person was seen by the in-reach team were recorded on System One
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Lack of a system for flagging or diverting urgent communications during staff absence
Wider context from the report “Re: Secretary of State for Justice
Alex Kelly a vulnerable looked after child of 15 years with complex unresolved emotional issues and unmanaged mental health issues was sentenced to a Detention and Training Order to be served at a Young Offender’s Institution without the benefit of a forensic psychiatric assessment. Whilst I heard evidence from a psychiatrist associate of Cookham Wood YOI that the mental health in-reach team were able to address Alex’s mental health needs whilst in custody, I am aware of the deaths of a number of other children in custody who similarly had not had forensic psychiatric assessments and it is for this reason I am reporting the concern. Whilst hearing evidence in relation to lessons learned I heard from the Service Manager of Medway Youth Offending Team that they have now secured the services of a psychiatric mental health nurse to assist them in the effective management of the young people for whom they have responsibilities which I was told was proving effective and is to be continued.
Alex Kelly was under an ACCT between the 23rd December 2011 and 3rd January 2012 and 6th January 2012 until his death. During the operation of the ACCT there was a continued conflict between the ACCT process and disciplinary procedures; outside agencies and carers were not asked to contribute; specific acts by Alex were seen as obstructive/challenging behaviour rather than signs of distress or a means of communicating that he needed help (his foster carers who had not been asked to contribute had some experience of Alex using non-verbal methods of communication); the ACCT reviews tended to focus on addressing specific or recent behaviours rather than the reason for the behaviour; although Alex was frequently mentioned at weekly safer regimes multidisciplinary meetings, a holistic approach was never adopted as to how he could best be supported or whether the YOI could support his needs.
Re: Tower Hamlets
1. Allocation
a) Alex Kelly was without a named social worker for a period of two months at a time when he was in danger of being sent to custody and after he was sent to custody. Difficulties in allocation were not escalated to senior management
2. IT
a) Social workers did not transfer documentation including emails onto Framework in a timely manner or at all
b) There was no system in place for ensuring that urgent electronic communications were flagged/diverted when the recipient was absent from work
3. Custody
a) Social workers did not all appear to appreciate that their responsibilities as Corporate Parent included a role in a looked after child’s welfare whilst in custody
Re: Medway Youth Offending Team
1. Involvement with other agencies
a) Shortcomings in other agencies which affected the ability of the YOT to manage the young person were not brought to the attention of management
2. Placement within the Secure Estate
a) There were inconsistencies in recommendations as to placement in a STC/YOI which were not reconciled
b) Youth Offending Team keyworkers did not all appear to appreciate that their responsibilities included a role in the young person’s welfare whilst in custody
c) Members of the Youth Offending Team did not all appear to appreciate that the Youth Offending Team could initiate a transfer within the secure estate
3. Caseworker based at Cookham Wood YOI
a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person
b) Although involved in the ACCT reviews the caseworker was unaware of the range of options available to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews
c) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release
Re: Cookham Wood YOI
1. Communication with outside agencies
a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person
2. ACCT
a) Officers were inconsistent in the recording of significant events; entries being made in either the wing observation log, ACCT ongoing record or not at all
b) At least one officer did not appear to appreciate the importance of significant incidents/disclosures or report them
c) Significant events in a lengthy ongoing record were not highlighted and therefore not obvious to officers reviewing safeguarding provisions
d) Officers were unaware of the need to involve outside agencies in the ACCT review process, the range of options available to them to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews
e) The safer regimes meetings were not provided with all relevant information and were not used to their full effect. The minutes of the meetings were not fully recorded
f) A holistic approach was not taken to the safe management of the young person during ACCT reviews or Safer Regimes meetings when it was apparent that he was struggling with the regime and that interventions were not working
3. Conflict between Regimes
a) Officers did not always seek advice before placing the young person on report for tattooing when there was an indication in the ACCT documentation that adjudication awards would lead to a heighted risk of self-harm
b) There was a conflict between the use of a behaviour improvement plan and adjudications which was not recognised at the time
4. Early Release
a) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release
5.Cell entry
a) There appeared to be an inflexible approach to cell entry requiring the presence of three prison officers even though YOI was in patrol state and concerns were sufficient to require entry
Re: Healthcare at Cookham Wood
NB: the service provider has changed since the death of Alex Kelly. The new provider is in the process of determining the systems and procedures being put in place at Cookham Wood
1. Sharing of Information
a) Officers concerned with the management of the young person were not informed in terms of his non-compliance with medication and the potential effect of the failure to take the medication
2. Medication management
a) a)Medication was found stockpiled in the young person’s cell; staff dispensing medication had not ensured it had been taken when it was probably recorded as having been taken
b) b)Any failure to take medication was not sufficiently flagged for healthcare/prison staff to deal with the issue
3.Recording of information
a) Not all occasions when the young person was seen by the in-reach team were recorded on System One
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable 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 seek advice before disciplinary action indicated increased self-harm risk
Wider context from the report “Re: Secretary of State for Justice
Alex Kelly a vulnerable looked after child of 15 years with complex unresolved emotional issues and unmanaged mental health issues was sentenced to a Detention and Training Order to be served at a Young Offender’s Institution without the benefit of a forensic psychiatric assessment. Whilst I heard evidence from a psychiatrist associate of Cookham Wood YOI that the mental health in-reach team were able to address Alex’s mental health needs whilst in custody, I am aware of the deaths of a number of other children in custody who similarly had not had forensic psychiatric assessments and it is for this reason I am reporting the concern. Whilst hearing evidence in relation to lessons learned I heard from the Service Manager of Medway Youth Offending Team that they have now secured the services of a psychiatric mental health nurse to assist them in the effective management of the young people for whom they have responsibilities which I was told was proving effective and is to be continued.
Alex Kelly was under an ACCT between the 23rd December 2011 and 3rd January 2012 and 6th January 2012 until his death. During the operation of the ACCT there was a continued conflict between the ACCT process and disciplinary procedures; outside agencies and carers were not asked to contribute; specific acts by Alex were seen as obstructive/challenging behaviour rather than signs of distress or a means of communicating that he needed help (his foster carers who had not been asked to contribute had some experience of Alex using non-verbal methods of communication); the ACCT reviews tended to focus on addressing specific or recent behaviours rather than the reason for the behaviour; although Alex was frequently mentioned at weekly safer regimes multidisciplinary meetings, a holistic approach was never adopted as to how he could best be supported or whether the YOI could support his needs.
Re: Tower Hamlets
1. Allocation
a) Alex Kelly was without a named social worker for a period of two months at a time when he was in danger of being sent to custody and after he was sent to custody. Difficulties in allocation were not escalated to senior management
2. IT
a) Social workers did not transfer documentation including emails onto Framework in a timely manner or at all
b) There was no system in place for ensuring that urgent electronic communications were flagged/diverted when the recipient was absent from work
3. Custody
a) Social workers did not all appear to appreciate that their responsibilities as Corporate Parent included a role in a looked after child’s welfare whilst in custody
Re: Medway Youth Offending Team
1. Involvement with other agencies
a) Shortcomings in other agencies which affected the ability of the YOT to manage the young person were not brought to the attention of management
2. Placement within the Secure Estate
a) There were inconsistencies in recommendations as to placement in a STC/YOI which were not reconciled
b) Youth Offending Team keyworkers did not all appear to appreciate that their responsibilities included a role in the young person’s welfare whilst in custody
c) Members of the Youth Offending Team did not all appear to appreciate that the Youth Offending Team could initiate a transfer within the secure estate
3. Caseworker based at Cookham Wood YOI
a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person
b) Although involved in the ACCT reviews the caseworker was unaware of the range of options available to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews
c) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release
Re: Cookham Wood YOI
1. Communication with outside agencies
a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person
2. ACCT
a) Officers were inconsistent in the recording of significant events; entries being made in either the wing observation log, ACCT ongoing record or not at all
b) At least one officer did not appear to appreciate the importance of significant incidents/disclosures or report them
c) Significant events in a lengthy ongoing record were not highlighted and therefore not obvious to officers reviewing safeguarding provisions
d) Officers were unaware of the need to involve outside agencies in the ACCT review process, the range of options available to them to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews
e) The safer regimes meetings were not provided with all relevant information and were not used to their full effect. The minutes of the meetings were not fully recorded
f) A holistic approach was not taken to the safe management of the young person during ACCT reviews or Safer Regimes meetings when it was apparent that he was struggling with the regime and that interventions were not working
3. Conflict between Regimes
a) Officers did not always seek advice before placing the young person on report for tattooing when there was an indication in the ACCT documentation that adjudication awards would lead to a heighted risk of self-harm
b) There was a conflict between the use of a behaviour improvement plan and adjudications which was not recognised at the time
4. Early Release
a) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release
5.Cell entry
a) There appeared to be an inflexible approach to cell entry requiring the presence of three prison officers even though YOI was in patrol state and concerns were sufficient to require entry
Re: Healthcare at Cookham Wood
NB: the service provider has changed since the death of Alex Kelly. The new provider is in the process of determining the systems and procedures being put in place at Cookham Wood
1. Sharing of Information
a) Officers concerned with the management of the young person were not informed in terms of his non-compliance with medication and the potential effect of the failure to take the medication
2. Medication management
a) a)Medication was found stockpiled in the young person’s cell; staff dispensing medication had not ensured it had been taken when it was probably recorded as having been taken
b) b)Any failure to take medication was not sufficiently flagged for healthcare/prison staff to deal with the issue
3.Recording of information
a) Not all occasions when the young person was seen by the in-reach team were recorded on System One
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable 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 understand available safe-management options
Wider context from the report “Re: Secretary of State for Justice
Alex Kelly a vulnerable looked after child of 15 years with complex unresolved emotional issues and unmanaged mental health issues was sentenced to a Detention and Training Order to be served at a Young Offender’s Institution without the benefit of a forensic psychiatric assessment. Whilst I heard evidence from a psychiatrist associate of Cookham Wood YOI that the mental health in-reach team were able to address Alex’s mental health needs whilst in custody, I am aware of the deaths of a number of other children in custody who similarly had not had forensic psychiatric assessments and it is for this reason I am reporting the concern. Whilst hearing evidence in relation to lessons learned I heard from the Service Manager of Medway Youth Offending Team that they have now secured the services of a psychiatric mental health nurse to assist them in the effective management of the young people for whom they have responsibilities which I was told was proving effective and is to be continued.
Alex Kelly was under an ACCT between the 23rd December 2011 and 3rd January 2012 and 6th January 2012 until his death. During the operation of the ACCT there was a continued conflict between the ACCT process and disciplinary procedures; outside agencies and carers were not asked to contribute; specific acts by Alex were seen as obstructive/challenging behaviour rather than signs of distress or a means of communicating that he needed help (his foster carers who had not been asked to contribute had some experience of Alex using non-verbal methods of communication); the ACCT reviews tended to focus on addressing specific or recent behaviours rather than the reason for the behaviour; although Alex was frequently mentioned at weekly safer regimes multidisciplinary meetings, a holistic approach was never adopted as to how he could best be supported or whether the YOI could support his needs.
Re: Tower Hamlets
1. Allocation
a) Alex Kelly was without a named social worker for a period of two months at a time when he was in danger of being sent to custody and after he was sent to custody. Difficulties in allocation were not escalated to senior management
2. IT
a) Social workers did not transfer documentation including emails onto Framework in a timely manner or at all
b) There was no system in place for ensuring that urgent electronic communications were flagged/diverted when the recipient was absent from work
3. Custody
a) Social workers did not all appear to appreciate that their responsibilities as Corporate Parent included a role in a looked after child’s welfare whilst in custody
Re: Medway Youth Offending Team
1. Involvement with other agencies
a) Shortcomings in other agencies which affected the ability of the YOT to manage the young person were not brought to the attention of management
2. Placement within the Secure Estate
a) There were inconsistencies in recommendations as to placement in a STC/YOI which were not reconciled
b) Youth Offending Team keyworkers did not all appear to appreciate that their responsibilities included a role in the young person’s welfare whilst in custody
c) Members of the Youth Offending Team did not all appear to appreciate that the Youth Offending Team could initiate a transfer within the secure estate
3. Caseworker based at Cookham Wood YOI
a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person
b) Although involved in the ACCT reviews the caseworker was unaware of the range of options available to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews
c) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release
Re: Cookham Wood YOI
1. Communication with outside agencies
a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person
2. ACCT
a) Officers were inconsistent in the recording of significant events; entries being made in either the wing observation log, ACCT ongoing record or not at all
b) At least one officer did not appear to appreciate the importance of significant incidents/disclosures or report them
c) Significant events in a lengthy ongoing record were not highlighted and therefore not obvious to officers reviewing safeguarding provisions
d) Officers were unaware of the need to involve outside agencies in the ACCT review process, the range of options available to them to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews
e) The safer regimes meetings were not provided with all relevant information and were not used to their full effect. The minutes of the meetings were not fully recorded
f) A holistic approach was not taken to the safe management of the young person during ACCT reviews or Safer Regimes meetings when it was apparent that he was struggling with the regime and that interventions were not working
3. Conflict between Regimes
a) Officers did not always seek advice before placing the young person on report for tattooing when there was an indication in the ACCT documentation that adjudication awards would lead to a heighted risk of self-harm
b) There was a conflict between the use of a behaviour improvement plan and adjudications which was not recognised at the time
4. Early Release
a) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release
5.Cell entry
a) There appeared to be an inflexible approach to cell entry requiring the presence of three prison officers even though YOI was in patrol state and concerns were sufficient to require entry
Re: Healthcare at Cookham Wood
NB: the service provider has changed since the death of Alex Kelly. The new provider is in the process of determining the systems and procedures being put in place at Cookham Wood
1. Sharing of Information
a) Officers concerned with the management of the young person were not informed in terms of his non-compliance with medication and the potential effect of the failure to take the medication
2. Medication management
a) a)Medication was found stockpiled in the young person’s cell; staff dispensing medication had not ensured it had been taken when it was probably recorded as having been taken
b) b)Any failure to take medication was not sufficiently flagged for healthcare/prison staff to deal with the issue
3.Recording of information
a) Not all occasions when the young person was seen by the in-reach team were recorded on System One
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable 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 highlight significant events in ongoing safeguarding records
Wider context from the report “Re: Secretary of State for Justice
Alex Kelly a vulnerable looked after child of 15 years with complex unresolved emotional issues and unmanaged mental health issues was sentenced to a Detention and Training Order to be served at a Young Offender’s Institution without the benefit of a forensic psychiatric assessment. Whilst I heard evidence from a psychiatrist associate of Cookham Wood YOI that the mental health in-reach team were able to address Alex’s mental health needs whilst in custody, I am aware of the deaths of a number of other children in custody who similarly had not had forensic psychiatric assessments and it is for this reason I am reporting the concern. Whilst hearing evidence in relation to lessons learned I heard from the Service Manager of Medway Youth Offending Team that they have now secured the services of a psychiatric mental health nurse to assist them in the effective management of the young people for whom they have responsibilities which I was told was proving effective and is to be continued.
Alex Kelly was under an ACCT between the 23rd December 2011 and 3rd January 2012 and 6th January 2012 until his death. During the operation of the ACCT there was a continued conflict between the ACCT process and disciplinary procedures; outside agencies and carers were not asked to contribute; specific acts by Alex were seen as obstructive/challenging behaviour rather than signs of distress or a means of communicating that he needed help (his foster carers who had not been asked to contribute had some experience of Alex using non-verbal methods of communication); the ACCT reviews tended to focus on addressing specific or recent behaviours rather than the reason for the behaviour; although Alex was frequently mentioned at weekly safer regimes multidisciplinary meetings, a holistic approach was never adopted as to how he could best be supported or whether the YOI could support his needs.
Re: Tower Hamlets
1. Allocation
a) Alex Kelly was without a named social worker for a period of two months at a time when he was in danger of being sent to custody and after he was sent to custody. Difficulties in allocation were not escalated to senior management
2. IT
a) Social workers did not transfer documentation including emails onto Framework in a timely manner or at all
b) There was no system in place for ensuring that urgent electronic communications were flagged/diverted when the recipient was absent from work
3. Custody
a) Social workers did not all appear to appreciate that their responsibilities as Corporate Parent included a role in a looked after child’s welfare whilst in custody
Re: Medway Youth Offending Team
1. Involvement with other agencies
a) Shortcomings in other agencies which affected the ability of the YOT to manage the young person were not brought to the attention of management
2. Placement within the Secure Estate
a) There were inconsistencies in recommendations as to placement in a STC/YOI which were not reconciled
b) Youth Offending Team keyworkers did not all appear to appreciate that their responsibilities included a role in the young person’s welfare whilst in custody
c) Members of the Youth Offending Team did not all appear to appreciate that the Youth Offending Team could initiate a transfer within the secure estate
3. Caseworker based at Cookham Wood YOI
a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person
b) Although involved in the ACCT reviews the caseworker was unaware of the range of options available to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews
c) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release
Re: Cookham Wood YOI
1. Communication with outside agencies
a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person
2. ACCT
a) Officers were inconsistent in the recording of significant events; entries being made in either the wing observation log, ACCT ongoing record or not at all
b) At least one officer did not appear to appreciate the importance of significant incidents/disclosures or report them
c) Significant events in a lengthy ongoing record were not highlighted and therefore not obvious to officers reviewing safeguarding provisions
d) Officers were unaware of the need to involve outside agencies in the ACCT review process, the range of options available to them to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews
e) The safer regimes meetings were not provided with all relevant information and were not used to their full effect. The minutes of the meetings were not fully recorded
f) A holistic approach was not taken to the safe management of the young person during ACCT reviews or Safer Regimes meetings when it was apparent that he was struggling with the regime and that interventions were not working
3. Conflict between Regimes
a) Officers did not always seek advice before placing the young person on report for tattooing when there was an indication in the ACCT documentation that adjudication awards would lead to a heighted risk of self-harm
b) There was a conflict between the use of a behaviour improvement plan and adjudications which was not recognised at the time
4. Early Release
a) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release
5.Cell entry
a) There appeared to be an inflexible approach to cell entry requiring the presence of three prison officers even though YOI was in patrol state and concerns were sufficient to require entry
Re: Healthcare at Cookham Wood
NB: the service provider has changed since the death of Alex Kelly. The new provider is in the process of determining the systems and procedures being put in place at Cookham Wood
1. Sharing of Information
a) Officers concerned with the management of the young person were not informed in terms of his non-compliance with medication and the potential effect of the failure to take the medication
2. Medication management
a) a)Medication was found stockpiled in the young person’s cell; staff dispensing medication had not ensured it had been taken when it was probably recorded as having been taken
b) b)Any failure to take medication was not sufficiently flagged for healthcare/prison staff to deal with the issue
3.Recording of information
a) Not all occasions when the young person was seen by the in-reach team were recorded on System One
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to involve outside agencies and carers in safeguarding
Wider context from the report “Re: Secretary of State for Justice
Alex Kelly a vulnerable looked after child of 15 years with complex unresolved emotional issues and unmanaged mental health issues was sentenced to a Detention and Training Order to be served at a Young Offender’s Institution without the benefit of a forensic psychiatric assessment. Whilst I heard evidence from a psychiatrist associate of Cookham Wood YOI that the mental health in-reach team were able to address Alex’s mental health needs whilst in custody, I am aware of the deaths of a number of other children in custody who similarly had not had forensic psychiatric assessments and it is for this reason I am reporting the concern. Whilst hearing evidence in relation to lessons learned I heard from the Service Manager of Medway Youth Offending Team that they have now secured the services of a psychiatric mental health nurse to assist them in the effective management of the young people for whom they have responsibilities which I was told was proving effective and is to be continued.
Alex Kelly was under an ACCT between the 23rd December 2011 and 3rd January 2012 and 6th January 2012 until his death. During the operation of the ACCT there was a continued conflict between the ACCT process and disciplinary procedures; outside agencies and carers were not asked to contribute ; specific acts by Alex were seen as obstructive/challenging behaviour rather than signs of distress or a means of communicating that he needed help (his foster carers who had not been asked to contribute had some experience of Alex using non-verbal methods of communication); the ACCT reviews tended to focus on addressing specific or recent behaviours rather than the reason for the behaviour; although Alex was frequently mentioned at weekly safer regimes multidisciplinary meetings, a holistic approach was never adopted as to how he could best be supported or whether the YOI could support his needs.
Re: Tower Hamlets
1. Allocation
a) Alex Kelly was without a named social worker for a period of two months at a time when he was in danger of being sent to custody and after he was sent to custody. Difficulties in allocation were not escalated to senior management
2. IT
a) Social workers did not transfer documentation including emails onto Framework in a timely manner or at all
b) There was no system in place for ensuring that urgent electronic communications were flagged/diverted when the recipient was absent from work
3. Custody
a) Social workers did not all appear to appreciate that their responsibilities as Corporate Parent included a role in a looked after child’s welfare whilst in custody
Re: Medway Youth Offending Team
1. Involvement with other agencies
a) Shortcomings in other agencies which affected the ability of the YOT to manage the young person were not brought to the attention of management
2. Placement within the Secure Estate
a) There were inconsistencies in recommendations as to placement in a STC/YOI which were not reconciled
b) Youth Offending Team keyworkers did not all appear to appreciate that their responsibilities included a role in the young person’s welfare whilst in custody
c) Members of the Youth Offending Team did not all appear to appreciate that the Youth Offending Team could initiate a transfer within the secure estate
3. Caseworker based at Cookham Wood YOI
a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person
b) Although involved in the ACCT reviews the caseworker was unaware of the range of options available to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews
c) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release
Re: Cookham Wood YOI
1. Communication with outside agencies
a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person
2. ACCT
a) Officers were inconsistent in the recording of significant events; entries being made in either the wing observation log, ACCT ongoing record or not at all
b) At least one officer did not appear to appreciate the importance of significant incidents/disclosures or report them
c) Significant events in a lengthy ongoing record were not highlighted and therefore not obvious to officers reviewing safeguarding provisions
d) Officers were unaware of the need to involve outside agencies in the ACCT review process, the range of options available to them to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews
e) The safer regimes meetings were not provided with all relevant information and were not used to their full effect. The minutes of the meetings were not fully recorded
f) A holistic approach was not taken to the safe management of the young person during ACCT reviews or Safer Regimes meetings when it was apparent that he was struggling with the regime and that interventions were not working
3. Conflict between Regimes
a) Officers did not always seek advice before placing the young person on report for tattooing when there was an indication in the ACCT documentation that adjudication awards would lead to a heighted risk of self-harm
b) There was a conflict between the use of a behaviour improvement plan and adjudications which was not recognised at the time
4. Early Release
a) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release
5.Cell entry
a) There appeared to be an inflexible approach to cell entry requiring the presence of three prison officers even though YOI was in patrol state and concerns were sufficient to require entry
Re: Healthcare at Cookham Wood
NB: the service provider has changed since the death of Alex Kelly. The new provider is in the process of determining the systems and procedures being put in place at Cookham Wood
1. Sharing of Information
a) Officers concerned with the management of the young person were not informed in terms of his non-compliance with medication and the potential effect of the failure to take the medication
2. Medication management
a) a)Medication was found stockpiled in the young person’s cell; staff dispensing medication had not ensured it had been taken when it was probably recorded as having been taken
b) b)Any failure to take medication was not sufficiently flagged for healthcare/prison staff to deal with the issue
3.Recording of information
a) Not all occasions when the young person was seen by the in-reach team were recorded on System One
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable 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 reconcile inconsistent secure-placement recommendations
Wider context from the report “Re: Secretary of State for Justice
Alex Kelly a vulnerable looked after child of 15 years with complex unresolved emotional issues and unmanaged mental health issues was sentenced to a Detention and Training Order to be served at a Young Offender’s Institution without the benefit of a forensic psychiatric assessment. Whilst I heard evidence from a psychiatrist associate of Cookham Wood YOI that the mental health in-reach team were able to address Alex’s mental health needs whilst in custody, I am aware of the deaths of a number of other children in custody who similarly had not had forensic psychiatric assessments and it is for this reason I am reporting the concern. Whilst hearing evidence in relation to lessons learned I heard from the Service Manager of Medway Youth Offending Team that they have now secured the services of a psychiatric mental health nurse to assist them in the effective management of the young people for whom they have responsibilities which I was told was proving effective and is to be continued.
Alex Kelly was under an ACCT between the 23rd December 2011 and 3rd January 2012 and 6th January 2012 until his death. During the operation of the ACCT there was a continued conflict between the ACCT process and disciplinary procedures; outside agencies and carers were not asked to contribute; specific acts by Alex were seen as obstructive/challenging behaviour rather than signs of distress or a means of communicating that he needed help (his foster carers who had not been asked to contribute had some experience of Alex using non-verbal methods of communication); the ACCT reviews tended to focus on addressing specific or recent behaviours rather than the reason for the behaviour; although Alex was frequently mentioned at weekly safer regimes multidisciplinary meetings, a holistic approach was never adopted as to how he could best be supported or whether the YOI could support his needs.
Re: Tower Hamlets
1. Allocation
a) Alex Kelly was without a named social worker for a period of two months at a time when he was in danger of being sent to custody and after he was sent to custody. Difficulties in allocation were not escalated to senior management
2. IT
a) Social workers did not transfer documentation including emails onto Framework in a timely manner or at all
b) There was no system in place for ensuring that urgent electronic communications were flagged/diverted when the recipient was absent from work
3. Custody
a) Social workers did not all appear to appreciate that their responsibilities as Corporate Parent included a role in a looked after child’s welfare whilst in custody
Re: Medway Youth Offending Team
1. Involvement with other agencies
a) Shortcomings in other agencies which affected the ability of the YOT to manage the young person were not brought to the attention of management
2. Placement within the Secure Estate
a) There were inconsistencies in recommendations as to placement in a STC/YOI which were not reconciled
b) Youth Offending Team keyworkers did not all appear to appreciate that their responsibilities included a role in the young person’s welfare whilst in custody
c) Members of the Youth Offending Team did not all appear to appreciate that the Youth Offending Team could initiate a transfer within the secure estate
3. Caseworker based at Cookham Wood YOI
a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person
b) Although involved in the ACCT reviews the caseworker was unaware of the range of options available to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews
c) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release
Re: Cookham Wood YOI
1. Communication with outside agencies
a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person
2. ACCT
a) Officers were inconsistent in the recording of significant events; entries being made in either the wing observation log, ACCT ongoing record or not at all
b) At least one officer did not appear to appreciate the importance of significant incidents/disclosures or report them
c) Significant events in a lengthy ongoing record were not highlighted and therefore not obvious to officers reviewing safeguarding provisions
d) Officers were unaware of the need to involve outside agencies in the ACCT review process, the range of options available to them to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews
e) The safer regimes meetings were not provided with all relevant information and were not used to their full effect. The minutes of the meetings were not fully recorded
f) A holistic approach was not taken to the safe management of the young person during ACCT reviews or Safer Regimes meetings when it was apparent that he was struggling with the regime and that interventions were not working
3. Conflict between Regimes
a) Officers did not always seek advice before placing the young person on report for tattooing when there was an indication in the ACCT documentation that adjudication awards would lead to a heighted risk of self-harm
b) There was a conflict between the use of a behaviour improvement plan and adjudications which was not recognised at the time
4. Early Release
a) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release
5.Cell entry
a) There appeared to be an inflexible approach to cell entry requiring the presence of three prison officers even though YOI was in patrol state and concerns were sufficient to require entry
Re: Healthcare at Cookham Wood
NB: the service provider has changed since the death of Alex Kelly. The new provider is in the process of determining the systems and procedures being put in place at Cookham Wood
1. Sharing of Information
a) Officers concerned with the management of the young person were not informed in terms of his non-compliance with medication and the potential effect of the failure to take the medication
2. Medication management
a) a)Medication was found stockpiled in the young person’s cell; staff dispensing medication had not ensured it had been taken when it was probably recorded as having been taken
b) b)Any failure to take medication was not sufficiently flagged for healthcare/prison staff to deal with the issue
3.Recording of information
a) Not all occasions when the young person was seen by the in-reach team were recorded on System One
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable 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 and involve agencies and carers in custodial welfare management
Wider context from the report “Re: Secretary of State for Justice
Alex Kelly a vulnerable looked after child of 15 years with complex unresolved emotional issues and unmanaged mental health issues was sentenced to a Detention and Training Order to be served at a Young Offender’s Institution without the benefit of a forensic psychiatric assessment. Whilst I heard evidence from a psychiatrist associate of Cookham Wood YOI that the mental health in-reach team were able to address Alex’s mental health needs whilst in custody, I am aware of the deaths of a number of other children in custody who similarly had not had forensic psychiatric assessments and it is for this reason I am reporting the concern. Whilst hearing evidence in relation to lessons learned I heard from the Service Manager of Medway Youth Offending Team that they have now secured the services of a psychiatric mental health nurse to assist them in the effective management of the young people for whom they have responsibilities which I was told was proving effective and is to be continued.
Alex Kelly was under an ACCT between the 23rd December 2011 and 3rd January 2012 and 6th January 2012 until his death. During the operation of the ACCT there was a continued conflict between the ACCT process and disciplinary procedures; outside agencies and carers were not asked to contribute; specific acts by Alex were seen as obstructive/challenging behaviour rather than signs of distress or a means of communicating that he needed help (his foster carers who had not been asked to contribute had some experience of Alex using non-verbal methods of communication); the ACCT reviews tended to focus on addressing specific or recent behaviours rather than the reason for the behaviour; although Alex was frequently mentioned at weekly safer regimes multidisciplinary meetings, a holistic approach was never adopted as to how he could best be supported or whether the YOI could support his needs.
Re: Tower Hamlets
1. Allocation
a) Alex Kelly was without a named social worker for a period of two months at a time when he was in danger of being sent to custody and after he was sent to custody. Difficulties in allocation were not escalated to senior management
2. IT
a) Social workers did not transfer documentation including emails onto Framework in a timely manner or at all
b) There was no system in place for ensuring that urgent electronic communications were flagged/diverted when the recipient was absent from work
3. Custody
a) Social workers did not all appear to appreciate that their responsibilities as Corporate Parent included a role in a looked after child’s welfare whilst in custody
Re: Medway Youth Offending Team
1. Involvement with other agencies
a) Shortcomings in other agencies which affected the ability of the YOT to manage the young person were not brought to the attention of management
2. Placement within the Secure Estate
a) There were inconsistencies in recommendations as to placement in a STC/YOI which were not reconciled
b) Youth Offending Team keyworkers did not all appear to appreciate that their responsibilities included a role in the young person’s welfare whilst in custody
c) Members of the Youth Offending Team did not all appear to appreciate that the Youth Offending Team could initiate a transfer within the secure estate
3. Caseworker based at Cookham Wood YOI
a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person
b) Although involved in the ACCT reviews the caseworker was unaware of the range of options available to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews
c) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release
Re: Cookham Wood YOI
1. Communication with outside agencies
a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person
2. ACCT
a) Officers were inconsistent in the recording of significant events; entries being made in either the wing observation log, ACCT ongoing record or not at all
b) At least one officer did not appear to appreciate the importance of significant incidents/disclosures or report them
c) Significant events in a lengthy ongoing record were not highlighted and therefore not obvious to officers reviewing safeguarding provisions
d) Officers were unaware of the need to involve outside agencies in the ACCT review process, the range of options available to them to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews
e) The safer regimes meetings were not provided with all relevant information and were not used to their full effect. The minutes of the meetings were not fully recorded
f) A holistic approach was not taken to the safe management of the young person during ACCT reviews or Safer Regimes meetings when it was apparent that he was struggling with the regime and that interventions were not working
3. Conflict between Regimes
a) Officers did not always seek advice before placing the young person on report for tattooing when there was an indication in the ACCT documentation that adjudication awards would lead to a heighted risk of self-harm
b) There was a conflict between the use of a behaviour improvement plan and adjudications which was not recognised at the time
4. Early Release
a) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release
5.Cell entry
a) There appeared to be an inflexible approach to cell entry requiring the presence of three prison officers even though YOI was in patrol state and concerns were sufficient to require entry
Re: Healthcare at Cookham Wood
NB: the service provider has changed since the death of Alex Kelly. The new provider is in the process of determining the systems and procedures being put in place at Cookham Wood
1. Sharing of Information
a) Officers concerned with the management of the young person were not informed in terms of his non-compliance with medication and the potential effect of the failure to take the medication
2. Medication management
a) a)Medication was found stockpiled in the young person’s cell; staff dispensing medication had not ensured it had been taken when it was probably recorded as having been taken
b) b)Any failure to take medication was not sufficiently flagged for healthcare/prison staff to deal with the issue
3.Recording of information
a) Not all occasions when the young person was seen by the in-reach team were recorded on System One
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable 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 reviews to address reasons for behaviour
Wider context from the report “Re: Secretary of State for Justice
Alex Kelly a vulnerable looked after child of 15 years with complex unresolved emotional issues and unmanaged mental health issues was sentenced to a Detention and Training Order to be served at a Young Offender’s Institution without the benefit of a forensic psychiatric assessment. Whilst I heard evidence from a psychiatrist associate of Cookham Wood YOI that the mental health in-reach team were able to address Alex’s mental health needs whilst in custody, I am aware of the deaths of a number of other children in custody who similarly had not had forensic psychiatric assessments and it is for this reason I am reporting the concern. Whilst hearing evidence in relation to lessons learned I heard from the Service Manager of Medway Youth Offending Team that they have now secured the services of a psychiatric mental health nurse to assist them in the effective management of the young people for whom they have responsibilities which I was told was proving effective and is to be continued.
Alex Kelly was under an ACCT between the 23rd December 2011 and 3rd January 2012 and 6th January 2012 until his death. During the operation of the ACCT there was a continued conflict between the ACCT process and disciplinary procedures; outside agencies and carers were not asked to contribute; specific acts by Alex were seen as obstructive/challenging behaviour rather than signs of distress or a means of communicating that he needed help (his foster carers who had not been asked to contribute had some experience of Alex using non-verbal methods of communication); the ACCT reviews tended to focus on addressing specific or recent behaviours rather than the reason for the behaviour ; although Alex was frequently mentioned at weekly safer regimes multidisciplinary meetings, a holistic approach was never adopted as to how he could best be supported or whether the YOI could support his needs.
Re: Tower Hamlets
1. Allocation
a) Alex Kelly was without a named social worker for a period of two months at a time when he was in danger of being sent to custody and after he was sent to custody. Difficulties in allocation were not escalated to senior management
2. IT
a) Social workers did not transfer documentation including emails onto Framework in a timely manner or at all
b) There was no system in place for ensuring that urgent electronic communications were flagged/diverted when the recipient was absent from work
3. Custody
a) Social workers did not all appear to appreciate that their responsibilities as Corporate Parent included a role in a looked after child’s welfare whilst in custody
Re: Medway Youth Offending Team
1. Involvement with other agencies
a) Shortcomings in other agencies which affected the ability of the YOT to manage the young person were not brought to the attention of management
2. Placement within the Secure Estate
a) There were inconsistencies in recommendations as to placement in a STC/YOI which were not reconciled
b) Youth Offending Team keyworkers did not all appear to appreciate that their responsibilities included a role in the young person’s welfare whilst in custody
c) Members of the Youth Offending Team did not all appear to appreciate that the Youth Offending Team could initiate a transfer within the secure estate
3. Caseworker based at Cookham Wood YOI
a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person
b) Although involved in the ACCT reviews the caseworker was unaware of the range of options available to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews
c) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release
Re: Cookham Wood YOI
1. Communication with outside agencies
a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person
2. ACCT
a) Officers were inconsistent in the recording of significant events; entries being made in either the wing observation log, ACCT ongoing record or not at all
b) At least one officer did not appear to appreciate the importance of significant incidents/disclosures or report them
c) Significant events in a lengthy ongoing record were not highlighted and therefore not obvious to officers reviewing safeguarding provisions
d) Officers were unaware of the need to involve outside agencies in the ACCT review process, the range of options available to them to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews
e) The safer regimes meetings were not provided with all relevant information and were not used to their full effect. The minutes of the meetings were not fully recorded
f) A holistic approach was not taken to the safe management of the young person during ACCT reviews or Safer Regimes meetings when it was apparent that he was struggling with the regime and that interventions were not working
3. Conflict between Regimes
a) Officers did not always seek advice before placing the young person on report for tattooing when there was an indication in the ACCT documentation that adjudication awards would lead to a heighted risk of self-harm
b) There was a conflict between the use of a behaviour improvement plan and adjudications which was not recognised at the time
4. Early Release
a) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release
5.Cell entry
a) There appeared to be an inflexible approach to cell entry requiring the presence of three prison officers even though YOI was in patrol state and concerns were sufficient to require entry
Re: Healthcare at Cookham Wood
NB: the service provider has changed since the death of Alex Kelly. The new provider is in the process of determining the systems and procedures being put in place at Cookham Wood
1. Sharing of Information
a) Officers concerned with the management of the young person were not informed in terms of his non-compliance with medication and the potential effect of the failure to take the medication
2. Medication management
a) a)Medication was found stockpiled in the young person’s cell; staff dispensing medication had not ensured it had been taken when it was probably recorded as having been taken
b) b)Any failure to take medication was not sufficiently flagged for healthcare/prison staff to deal with the issue
3.Recording of information
a) Not all occasions when the young person was seen by the in-reach team were recorded on System One
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable 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 understand YOT authority to initiate secure-estate transfers
Wider context from the report “Re: Secretary of State for Justice
Alex Kelly a vulnerable looked after child of 15 years with complex unresolved emotional issues and unmanaged mental health issues was sentenced to a Detention and Training Order to be served at a Young Offender’s Institution without the benefit of a forensic psychiatric assessment. Whilst I heard evidence from a psychiatrist associate of Cookham Wood YOI that the mental health in-reach team were able to address Alex’s mental health needs whilst in custody, I am aware of the deaths of a number of other children in custody who similarly had not had forensic psychiatric assessments and it is for this reason I am reporting the concern. Whilst hearing evidence in relation to lessons learned I heard from the Service Manager of Medway Youth Offending Team that they have now secured the services of a psychiatric mental health nurse to assist them in the effective management of the young people for whom they have responsibilities which I was told was proving effective and is to be continued.
Alex Kelly was under an ACCT between the 23rd December 2011 and 3rd January 2012 and 6th January 2012 until his death. During the operation of the ACCT there was a continued conflict between the ACCT process and disciplinary procedures; outside agencies and carers were not asked to contribute; specific acts by Alex were seen as obstructive/challenging behaviour rather than signs of distress or a means of communicating that he needed help (his foster carers who had not been asked to contribute had some experience of Alex using non-verbal methods of communication); the ACCT reviews tended to focus on addressing specific or recent behaviours rather than the reason for the behaviour; although Alex was frequently mentioned at weekly safer regimes multidisciplinary meetings, a holistic approach was never adopted as to how he could best be supported or whether the YOI could support his needs.
Re: Tower Hamlets
1. Allocation
a) Alex Kelly was without a named social worker for a period of two months at a time when he was in danger of being sent to custody and after he was sent to custody. Difficulties in allocation were not escalated to senior management
2. IT
a) Social workers did not transfer documentation including emails onto Framework in a timely manner or at all
b) There was no system in place for ensuring that urgent electronic communications were flagged/diverted when the recipient was absent from work
3. Custody
a) Social workers did not all appear to appreciate that their responsibilities as Corporate Parent included a role in a looked after child’s welfare whilst in custody
Re: Medway Youth Offending Team
1. Involvement with other agencies
a) Shortcomings in other agencies which affected the ability of the YOT to manage the young person were not brought to the attention of management
2. Placement within the Secure Estate
a) There were inconsistencies in recommendations as to placement in a STC/YOI which were not reconciled
b) Youth Offending Team keyworkers did not all appear to appreciate that their responsibilities included a role in the young person’s welfare whilst in custody
c) Members of the Youth Offending Team did not all appear to appreciate that the Youth Offending Team could initiate a transfer within the secure estate
3. Caseworker based at Cookham Wood YOI
a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person
b) Although involved in the ACCT reviews the caseworker was unaware of the range of options available to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews
c) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release
Re: Cookham Wood YOI
1. Communication with outside agencies
a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person
2. ACCT
a) Officers were inconsistent in the recording of significant events; entries being made in either the wing observation log, ACCT ongoing record or not at all
b) At least one officer did not appear to appreciate the importance of significant incidents/disclosures or report them
c) Significant events in a lengthy ongoing record were not highlighted and therefore not obvious to officers reviewing safeguarding provisions
d) Officers were unaware of the need to involve outside agencies in the ACCT review process, the range of options available to them to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews
e) The safer regimes meetings were not provided with all relevant information and were not used to their full effect. The minutes of the meetings were not fully recorded
f) A holistic approach was not taken to the safe management of the young person during ACCT reviews or Safer Regimes meetings when it was apparent that he was struggling with the regime and that interventions were not working
3. Conflict between Regimes
a) Officers did not always seek advice before placing the young person on report for tattooing when there was an indication in the ACCT documentation that adjudication awards would lead to a heighted risk of self-harm
b) There was a conflict between the use of a behaviour improvement plan and adjudications which was not recognised at the time
4. Early Release
a) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release
5.Cell entry
a) There appeared to be an inflexible approach to cell entry requiring the presence of three prison officers even though YOI was in patrol state and concerns were sufficient to require entry
Re: Healthcare at Cookham Wood
NB: the service provider has changed since the death of Alex Kelly. The new provider is in the process of determining the systems and procedures being put in place at Cookham Wood
1. Sharing of Information
a) Officers concerned with the management of the young person were not informed in terms of his non-compliance with medication and the potential effect of the failure to take the medication
2. Medication management
a) a)Medication was found stockpiled in the young person’s cell; staff dispensing medication had not ensured it had been taken when it was probably recorded as having been taken
b) b)Any failure to take medication was not sufficiently flagged for healthcare/prison staff to deal with the issue
3.Recording of information
a) Not all occasions when the young person was seen by the in-reach team were recorded on System One
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate interagency shortcomings affecting YOT management
Wider context from the report “Re: Secretary of State for Justice
Alex Kelly a vulnerable looked after child of 15 years with complex unresolved emotional issues and unmanaged mental health issues was sentenced to a Detention and Training Order to be served at a Young Offender’s Institution without the benefit of a forensic psychiatric assessment. Whilst I heard evidence from a psychiatrist associate of Cookham Wood YOI that the mental health in-reach team were able to address Alex’s mental health needs whilst in custody, I am aware of the deaths of a number of other children in custody who similarly had not had forensic psychiatric assessments and it is for this reason I am reporting the concern. Whilst hearing evidence in relation to lessons learned I heard from the Service Manager of Medway Youth Offending Team that they have now secured the services of a psychiatric mental health nurse to assist them in the effective management of the young people for whom they have responsibilities which I was told was proving effective and is to be continued.
Alex Kelly was under an ACCT between the 23rd December 2011 and 3rd January 2012 and 6th January 2012 until his death. During the operation of the ACCT there was a continued conflict between the ACCT process and disciplinary procedures; outside agencies and carers were not asked to contribute; specific acts by Alex were seen as obstructive/challenging behaviour rather than signs of distress or a means of communicating that he needed help (his foster carers who had not been asked to contribute had some experience of Alex using non-verbal methods of communication); the ACCT reviews tended to focus on addressing specific or recent behaviours rather than the reason for the behaviour; although Alex was frequently mentioned at weekly safer regimes multidisciplinary meetings, a holistic approach was never adopted as to how he could best be supported or whether the YOI could support his needs.
Re: Tower Hamlets
1. Allocation
a) Alex Kelly was without a named social worker for a period of two months at a time when he was in danger of being sent to custody and after he was sent to custody. Difficulties in allocation were not escalated to senior management
2. IT
a) Social workers did not transfer documentation including emails onto Framework in a timely manner or at all
b) There was no system in place for ensuring that urgent electronic communications were flagged/diverted when the recipient was absent from work
3. Custody
a) Social workers did not all appear to appreciate that their responsibilities as Corporate Parent included a role in a looked after child’s welfare whilst in custody
Re: Medway Youth Offending Team
1. Involvement with other agencies
a) Shortcomings in other agencies which affected the ability of the YOT to manage the young person were not brought to the attention of management
2. Placement within the Secure Estate
a) There were inconsistencies in recommendations as to placement in a STC/YOI which were not reconciled
b) Youth Offending Team keyworkers did not all appear to appreciate that their responsibilities included a role in the young person’s welfare whilst in custody
c) Members of the Youth Offending Team did not all appear to appreciate that the Youth Offending Team could initiate a transfer within the secure estate
3. Caseworker based at Cookham Wood YOI
a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person
b) Although involved in the ACCT reviews the caseworker was unaware of the range of options available to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews
c) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release
Re: Cookham Wood YOI
1. Communication with outside agencies
a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person
2. ACCT
a) Officers were inconsistent in the recording of significant events; entries being made in either the wing observation log, ACCT ongoing record or not at all
b) At least one officer did not appear to appreciate the importance of significant incidents/disclosures or report them
c) Significant events in a lengthy ongoing record were not highlighted and therefore not obvious to officers reviewing safeguarding provisions
d) Officers were unaware of the need to involve outside agencies in the ACCT review process, the range of options available to them to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews
e) The safer regimes meetings were not provided with all relevant information and were not used to their full effect. The minutes of the meetings were not fully recorded
f) A holistic approach was not taken to the safe management of the young person during ACCT reviews or Safer Regimes meetings when it was apparent that he was struggling with the regime and that interventions were not working
3. Conflict between Regimes
a) Officers did not always seek advice before placing the young person on report for tattooing when there was an indication in the ACCT documentation that adjudication awards would lead to a heighted risk of self-harm
b) There was a conflict between the use of a behaviour improvement plan and adjudications which was not recognised at the time
4. Early Release
a) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release
5.Cell entry
a) There appeared to be an inflexible approach to cell entry requiring the presence of three prison officers even though YOI was in patrol state and concerns were sufficient to require entry
Re: Healthcare at Cookham Wood
NB: the service provider has changed since the death of Alex Kelly. The new provider is in the process of determining the systems and procedures being put in place at Cookham Wood
1. Sharing of Information
a) Officers concerned with the management of the young person were not informed in terms of his non-compliance with medication and the potential effect of the failure to take the medication
2. Medication management
a) a)Medication was found stockpiled in the young person’s cell; staff dispensing medication had not ensured it had been taken when it was probably recorded as having been taken
b) b)Any failure to take medication was not sufficiently flagged for healthcare/prison staff to deal with the issue
3.Recording of information
a) Not all occasions when the young person was seen by the in-reach team were recorded on System One
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable 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 adopt a holistic approach to custodial support
Wider context from the report “Re: Secretary of State for Justice
Alex Kelly a vulnerable looked after child of 15 years with complex unresolved emotional issues and unmanaged mental health issues was sentenced to a Detention and Training Order to be served at a Young Offender’s Institution without the benefit of a forensic psychiatric assessment. Whilst I heard evidence from a psychiatrist associate of Cookham Wood YOI that the mental health in-reach team were able to address Alex’s mental health needs whilst in custody, I am aware of the deaths of a number of other children in custody who similarly had not had forensic psychiatric assessments and it is for this reason I am reporting the concern. Whilst hearing evidence in relation to lessons learned I heard from the Service Manager of Medway Youth Offending Team that they have now secured the services of a psychiatric mental health nurse to assist them in the effective management of the young people for whom they have responsibilities which I was told was proving effective and is to be continued.
Alex Kelly was under an ACCT between the 23rd December 2011 and 3rd January 2012 and 6th January 2012 until his death. During the operation of the ACCT there was a continued conflict between the ACCT process and disciplinary procedures; outside agencies and carers were not asked to contribute; specific acts by Alex were seen as obstructive/challenging behaviour rather than signs of distress or a means of communicating that he needed help (his foster carers who had not been asked to contribute had some experience of Alex using non-verbal methods of communication); the ACCT reviews tended to focus on addressing specific or recent behaviours rather than the reason for the behaviour; although Alex was frequently mentioned at weekly safer regimes multidisciplinary meetings, a holistic approach was never adopted as to how he could best be supported or whether the YOI could support his needs .
Re: Tower Hamlets
1. Allocation
a) Alex Kelly was without a named social worker for a period of two months at a time when he was in danger of being sent to custody and after he was sent to custody. Difficulties in allocation were not escalated to senior management
2. IT
a) Social workers did not transfer documentation including emails onto Framework in a timely manner or at all
b) There was no system in place for ensuring that urgent electronic communications were flagged/diverted when the recipient was absent from work
3. Custody
a) Social workers did not all appear to appreciate that their responsibilities as Corporate Parent included a role in a looked after child’s welfare whilst in custody
Re: Medway Youth Offending Team
1. Involvement with other agencies
a) Shortcomings in other agencies which affected the ability of the YOT to manage the young person were not brought to the attention of management
2. Placement within the Secure Estate
a) There were inconsistencies in recommendations as to placement in a STC/YOI which were not reconciled
b) Youth Offending Team keyworkers did not all appear to appreciate that their responsibilities included a role in the young person’s welfare whilst in custody
c) Members of the Youth Offending Team did not all appear to appreciate that the Youth Offending Team could initiate a transfer within the secure estate
3. Caseworker based at Cookham Wood YOI
a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person
b) Although involved in the ACCT reviews the caseworker was unaware of the range of options available to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews
c) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release
Re: Cookham Wood YOI
1. Communication with outside agencies
a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person
2. ACCT
a) Officers were inconsistent in the recording of significant events; entries being made in either the wing observation log, ACCT ongoing record or not at all
b) At least one officer did not appear to appreciate the importance of significant incidents/disclosures or report them
c) Significant events in a lengthy ongoing record were not highlighted and therefore not obvious to officers reviewing safeguarding provisions
d) Officers were unaware of the need to involve outside agencies in the ACCT review process, the range of options available to them to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews
e) The safer regimes meetings were not provided with all relevant information and were not used to their full effect. The minutes of the meetings were not fully recorded
f) A holistic approach was not taken to the safe management of the young person during ACCT reviews or Safer Regimes meetings when it was apparent that he was struggling with the regime and that interventions were not working
3. Conflict between Regimes
a) Officers did not always seek advice before placing the young person on report for tattooing when there was an indication in the ACCT documentation that adjudication awards would lead to a heighted risk of self-harm
b) There was a conflict between the use of a behaviour improvement plan and adjudications which was not recognised at the time
4. Early Release
a) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release
5.Cell entry
a) There appeared to be an inflexible approach to cell entry requiring the presence of three prison officers even though YOI was in patrol state and concerns were sufficient to require entry
Re: Healthcare at Cookham Wood
NB: the service provider has changed since the death of Alex Kelly. The new provider is in the process of determining the systems and procedures being put in place at Cookham Wood
1. Sharing of Information
a) Officers concerned with the management of the young person were not informed in terms of his non-compliance with medication and the potential effect of the failure to take the medication
2. Medication management
a) a)Medication was found stockpiled in the young person’s cell; staff dispensing medication had not ensured it had been taken when it was probably recorded as having been taken
b) b)Any failure to take medication was not sufficiently flagged for healthcare/prison staff to deal with the issue
3.Recording of information
a) Not all occasions when the young person was seen by the in-reach team were recorded on System One
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable 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 understand corporate parenting responsibilities for children in custody
Wider context from the report “Re: Secretary of State for Justice
Alex Kelly a vulnerable looked after child of 15 years with complex unresolved emotional issues and unmanaged mental health issues was sentenced to a Detention and Training Order to be served at a Young Offender’s Institution without the benefit of a forensic psychiatric assessment. Whilst I heard evidence from a psychiatrist associate of Cookham Wood YOI that the mental health in-reach team were able to address Alex’s mental health needs whilst in custody, I am aware of the deaths of a number of other children in custody who similarly had not had forensic psychiatric assessments and it is for this reason I am reporting the concern. Whilst hearing evidence in relation to lessons learned I heard from the Service Manager of Medway Youth Offending Team that they have now secured the services of a psychiatric mental health nurse to assist them in the effective management of the young people for whom they have responsibilities which I was told was proving effective and is to be continued.
Alex Kelly was under an ACCT between the 23rd December 2011 and 3rd January 2012 and 6th January 2012 until his death. During the operation of the ACCT there was a continued conflict between the ACCT process and disciplinary procedures; outside agencies and carers were not asked to contribute; specific acts by Alex were seen as obstructive/challenging behaviour rather than signs of distress or a means of communicating that he needed help (his foster carers who had not been asked to contribute had some experience of Alex using non-verbal methods of communication); the ACCT reviews tended to focus on addressing specific or recent behaviours rather than the reason for the behaviour; although Alex was frequently mentioned at weekly safer regimes multidisciplinary meetings, a holistic approach was never adopted as to how he could best be supported or whether the YOI could support his needs.
Re: Tower Hamlets
1. Allocation
a) Alex Kelly was without a named social worker for a period of two months at a time when he was in danger of being sent to custody and after he was sent to custody. Difficulties in allocation were not escalated to senior management
2. IT
a) Social workers did not transfer documentation including emails onto Framework in a timely manner or at all
b) There was no system in place for ensuring that urgent electronic communications were flagged/diverted when the recipient was absent from work
3. Custody
a) Social workers did not all appear to appreciate that their responsibilities as Corporate Parent included a role in a looked after child’s welfare whilst in custody
Re: Medway Youth Offending Team
1. Involvement with other agencies
a) Shortcomings in other agencies which affected the ability of the YOT to manage the young person were not brought to the attention of management
2. Placement within the Secure Estate
a) There were inconsistencies in recommendations as to placement in a STC/YOI which were not reconciled
b) Youth Offending Team keyworkers did not all appear to appreciate that their responsibilities included a role in the young person’s welfare whilst in custody
c) Members of the Youth Offending Team did not all appear to appreciate that the Youth Offending Team could initiate a transfer within the secure estate
3. Caseworker based at Cookham Wood YOI
a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person
b) Although involved in the ACCT reviews the caseworker was unaware of the range of options available to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews
c) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release
Re: Cookham Wood YOI
1. Communication with outside agencies
a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person
2. ACCT
a) Officers were inconsistent in the recording of significant events; entries being made in either the wing observation log, ACCT ongoing record or not at all
b) At least one officer did not appear to appreciate the importance of significant incidents/disclosures or report them
c) Significant events in a lengthy ongoing record were not highlighted and therefore not obvious to officers reviewing safeguarding provisions
d) Officers were unaware of the need to involve outside agencies in the ACCT review process, the range of options available to them to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews
e) The safer regimes meetings were not provided with all relevant information and were not used to their full effect. The minutes of the meetings were not fully recorded
f) A holistic approach was not taken to the safe management of the young person during ACCT reviews or Safer Regimes meetings when it was apparent that he was struggling with the regime and that interventions were not working
3. Conflict between Regimes
a) Officers did not always seek advice before placing the young person on report for tattooing when there was an indication in the ACCT documentation that adjudication awards would lead to a heighted risk of self-harm
b) There was a conflict between the use of a behaviour improvement plan and adjudications which was not recognised at the time
4. Early Release
a) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release
5.Cell entry
a) There appeared to be an inflexible approach to cell entry requiring the presence of three prison officers even though YOI was in patrol state and concerns were sufficient to require entry
Re: Healthcare at Cookham Wood
NB: the service provider has changed since the death of Alex Kelly. The new provider is in the process of determining the systems and procedures being put in place at Cookham Wood
1. Sharing of Information
a) Officers concerned with the management of the young person were not informed in terms of his non-compliance with medication and the potential effect of the failure to take the medication
2. Medication management
a) a)Medication was found stockpiled in the young person’s cell; staff dispensing medication had not ensured it had been taken when it was probably recorded as having been taken
b) b)Any failure to take medication was not sufficiently flagged for healthcare/prison staff to deal with the issue
3.Recording of information
a) Not all occasions when the young person was seen by the in-reach team were recorded on System One
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Inconsistent recording of significant events across safeguarding records
Wider context from the report “Re: Secretary of State for Justice
Alex Kelly a vulnerable looked after child of 15 years with complex unresolved emotional issues and unmanaged mental health issues was sentenced to a Detention and Training Order to be served at a Young Offender’s Institution without the benefit of a forensic psychiatric assessment. Whilst I heard evidence from a psychiatrist associate of Cookham Wood YOI that the mental health in-reach team were able to address Alex’s mental health needs whilst in custody, I am aware of the deaths of a number of other children in custody who similarly had not had forensic psychiatric assessments and it is for this reason I am reporting the concern. Whilst hearing evidence in relation to lessons learned I heard from the Service Manager of Medway Youth Offending Team that they have now secured the services of a psychiatric mental health nurse to assist them in the effective management of the young people for whom they have responsibilities which I was told was proving effective and is to be continued.
Alex Kelly was under an ACCT between the 23rd December 2011 and 3rd January 2012 and 6th January 2012 until his death. During the operation of the ACCT there was a continued conflict between the ACCT process and disciplinary procedures; outside agencies and carers were not asked to contribute; specific acts by Alex were seen as obstructive/challenging behaviour rather than signs of distress or a means of communicating that he needed help (his foster carers who had not been asked to contribute had some experience of Alex using non-verbal methods of communication); the ACCT reviews tended to focus on addressing specific or recent behaviours rather than the reason for the behaviour; although Alex was frequently mentioned at weekly safer regimes multidisciplinary meetings, a holistic approach was never adopted as to how he could best be supported or whether the YOI could support his needs.
Re: Tower Hamlets
1. Allocation
a) Alex Kelly was without a named social worker for a period of two months at a time when he was in danger of being sent to custody and after he was sent to custody. Difficulties in allocation were not escalated to senior management
2. IT
a) Social workers did not transfer documentation including emails onto Framework in a timely manner or at all
b) There was no system in place for ensuring that urgent electronic communications were flagged/diverted when the recipient was absent from work
3. Custody
a) Social workers did not all appear to appreciate that their responsibilities as Corporate Parent included a role in a looked after child’s welfare whilst in custody
Re: Medway Youth Offending Team
1. Involvement with other agencies
a) Shortcomings in other agencies which affected the ability of the YOT to manage the young person were not brought to the attention of management
2. Placement within the Secure Estate
a) There were inconsistencies in recommendations as to placement in a STC/YOI which were not reconciled
b) Youth Offending Team keyworkers did not all appear to appreciate that their responsibilities included a role in the young person’s welfare whilst in custody
c) Members of the Youth Offending Team did not all appear to appreciate that the Youth Offending Team could initiate a transfer within the secure estate
3. Caseworker based at Cookham Wood YOI
a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person
b) Although involved in the ACCT reviews the caseworker was unaware of the range of options available to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews
c) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release
Re: Cookham Wood YOI
1. Communication with outside agencies
a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person
2. ACCT
a) Officers were inconsistent in the recording of significant events; entries being made in either the wing observation log, ACCT ongoing record or not at all
b) At least one officer did not appear to appreciate the importance of significant incidents/disclosures or report them
c) Significant events in a lengthy ongoing record were not highlighted and therefore not obvious to officers reviewing safeguarding provisions
d) Officers were unaware of the need to involve outside agencies in the ACCT review process, the range of options available to them to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews
e) The safer regimes meetings were not provided with all relevant information and were not used to their full effect. The minutes of the meetings were not fully recorded
f) A holistic approach was not taken to the safe management of the young person during ACCT reviews or Safer Regimes meetings when it was apparent that he was struggling with the regime and that interventions were not working
3. Conflict between Regimes
a) Officers did not always seek advice before placing the young person on report for tattooing when there was an indication in the ACCT documentation that adjudication awards would lead to a heighted risk of self-harm
b) There was a conflict between the use of a behaviour improvement plan and adjudications which was not recognised at the time
4. Early Release
a) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release
5.Cell entry
a) There appeared to be an inflexible approach to cell entry requiring the presence of three prison officers even though YOI was in patrol state and concerns were sufficient to require entry
Re: Healthcare at Cookham Wood
NB: the service provider has changed since the death of Alex Kelly. The new provider is in the process of determining the systems and procedures being put in place at Cookham Wood
1. Sharing of Information
a) Officers concerned with the management of the young person were not informed in terms of his non-compliance with medication and the potential effect of the failure to take the medication
2. Medication management
a) a)Medication was found stockpiled in the young person’s cell; staff dispensing medication had not ensured it had been taken when it was probably recorded as having been taken
b) b)Any failure to take medication was not sufficiently flagged for healthcare/prison staff to deal with the issue
3.Recording of information
a) Not all occasions when the young person was seen by the in-reach team were recorded on System One
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable 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 flag medication non-compliance for clinical and custodial action
Wider context from the report “Re: Secretary of State for Justice
Alex Kelly a vulnerable looked after child of 15 years with complex unresolved emotional issues and unmanaged mental health issues was sentenced to a Detention and Training Order to be served at a Young Offender’s Institution without the benefit of a forensic psychiatric assessment. Whilst I heard evidence from a psychiatrist associate of Cookham Wood YOI that the mental health in-reach team were able to address Alex’s mental health needs whilst in custody, I am aware of the deaths of a number of other children in custody who similarly had not had forensic psychiatric assessments and it is for this reason I am reporting the concern. Whilst hearing evidence in relation to lessons learned I heard from the Service Manager of Medway Youth Offending Team that they have now secured the services of a psychiatric mental health nurse to assist them in the effective management of the young people for whom they have responsibilities which I was told was proving effective and is to be continued.
Alex Kelly was under an ACCT between the 23rd December 2011 and 3rd January 2012 and 6th January 2012 until his death. During the operation of the ACCT there was a continued conflict between the ACCT process and disciplinary procedures; outside agencies and carers were not asked to contribute; specific acts by Alex were seen as obstructive/challenging behaviour rather than signs of distress or a means of communicating that he needed help (his foster carers who had not been asked to contribute had some experience of Alex using non-verbal methods of communication); the ACCT reviews tended to focus on addressing specific or recent behaviours rather than the reason for the behaviour; although Alex was frequently mentioned at weekly safer regimes multidisciplinary meetings, a holistic approach was never adopted as to how he could best be supported or whether the YOI could support his needs.
Re: Tower Hamlets
1. Allocation
a) Alex Kelly was without a named social worker for a period of two months at a time when he was in danger of being sent to custody and after he was sent to custody. Difficulties in allocation were not escalated to senior management
2. IT
a) Social workers did not transfer documentation including emails onto Framework in a timely manner or at all
b) There was no system in place for ensuring that urgent electronic communications were flagged/diverted when the recipient was absent from work
3. Custody
a) Social workers did not all appear to appreciate that their responsibilities as Corporate Parent included a role in a looked after child’s welfare whilst in custody
Re: Medway Youth Offending Team
1. Involvement with other agencies
a) Shortcomings in other agencies which affected the ability of the YOT to manage the young person were not brought to the attention of management
2. Placement within the Secure Estate
a) There were inconsistencies in recommendations as to placement in a STC/YOI which were not reconciled
b) Youth Offending Team keyworkers did not all appear to appreciate that their responsibilities included a role in the young person’s welfare whilst in custody
c) Members of the Youth Offending Team did not all appear to appreciate that the Youth Offending Team could initiate a transfer within the secure estate
3. Caseworker based at Cookham Wood YOI
a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person
b) Although involved in the ACCT reviews the caseworker was unaware of the range of options available to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews
c) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release
Re: Cookham Wood YOI
1. Communication with outside agencies
a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person
2. ACCT
a) Officers were inconsistent in the recording of significant events; entries being made in either the wing observation log, ACCT ongoing record or not at all
b) At least one officer did not appear to appreciate the importance of significant incidents/disclosures or report them
c) Significant events in a lengthy ongoing record were not highlighted and therefore not obvious to officers reviewing safeguarding provisions
d) Officers were unaware of the need to involve outside agencies in the ACCT review process, the range of options available to them to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews
e) The safer regimes meetings were not provided with all relevant information and were not used to their full effect. The minutes of the meetings were not fully recorded
f) A holistic approach was not taken to the safe management of the young person during ACCT reviews or Safer Regimes meetings when it was apparent that he was struggling with the regime and that interventions were not working
3. Conflict between Regimes
a) Officers did not always seek advice before placing the young person on report for tattooing when there was an indication in the ACCT documentation that adjudication awards would lead to a heighted risk of self-harm
b) There was a conflict between the use of a behaviour improvement plan and adjudications which was not recognised at the time
4. Early Release
a) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release
5.Cell entry
a) There appeared to be an inflexible approach to cell entry requiring the presence of three prison officers even though YOI was in patrol state and concerns were sufficient to require entry
Re: Healthcare at Cookham Wood
NB: the service provider has changed since the death of Alex Kelly. The new provider is in the process of determining the systems and procedures being put in place at Cookham Wood
1. Sharing of Information
a) Officers concerned with the management of the young person were not informed in terms of his non-compliance with medication and the potential effect of the failure to take the medication
2. Medication management
a) a)Medication was found stockpiled in the young person’s cell; staff dispensing medication had not ensured it had been taken when it was probably recorded as having been taken
b) b)Any failure to take medication was not sufficiently flagged for healthcare/prison staff to deal with the issue
3.Recording of information
a) Not all occasions when the young person was seen by the in-reach team were recorded on System One
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise or report significant incidents and disclosures
Wider context from the report “Re: Secretary of State for Justice
Alex Kelly a vulnerable looked after child of 15 years with complex unresolved emotional issues and unmanaged mental health issues was sentenced to a Detention and Training Order to be served at a Young Offender’s Institution without the benefit of a forensic psychiatric assessment. Whilst I heard evidence from a psychiatrist associate of Cookham Wood YOI that the mental health in-reach team were able to address Alex’s mental health needs whilst in custody, I am aware of the deaths of a number of other children in custody who similarly had not had forensic psychiatric assessments and it is for this reason I am reporting the concern. Whilst hearing evidence in relation to lessons learned I heard from the Service Manager of Medway Youth Offending Team that they have now secured the services of a psychiatric mental health nurse to assist them in the effective management of the young people for whom they have responsibilities which I was told was proving effective and is to be continued.
Alex Kelly was under an ACCT between the 23rd December 2011 and 3rd January 2012 and 6th January 2012 until his death. During the operation of the ACCT there was a continued conflict between the ACCT process and disciplinary procedures; outside agencies and carers were not asked to contribute; specific acts by Alex were seen as obstructive/challenging behaviour rather than signs of distress or a means of communicating that he needed help (his foster carers who had not been asked to contribute had some experience of Alex using non-verbal methods of communication); the ACCT reviews tended to focus on addressing specific or recent behaviours rather than the reason for the behaviour; although Alex was frequently mentioned at weekly safer regimes multidisciplinary meetings, a holistic approach was never adopted as to how he could best be supported or whether the YOI could support his needs.
Re: Tower Hamlets
1. Allocation
a) Alex Kelly was without a named social worker for a period of two months at a time when he was in danger of being sent to custody and after he was sent to custody. Difficulties in allocation were not escalated to senior management
2. IT
a) Social workers did not transfer documentation including emails onto Framework in a timely manner or at all
b) There was no system in place for ensuring that urgent electronic communications were flagged/diverted when the recipient was absent from work
3. Custody
a) Social workers did not all appear to appreciate that their responsibilities as Corporate Parent included a role in a looked after child’s welfare whilst in custody
Re: Medway Youth Offending Team
1. Involvement with other agencies
a) Shortcomings in other agencies which affected the ability of the YOT to manage the young person were not brought to the attention of management
2. Placement within the Secure Estate
a) There were inconsistencies in recommendations as to placement in a STC/YOI which were not reconciled
b) Youth Offending Team keyworkers did not all appear to appreciate that their responsibilities included a role in the young person’s welfare whilst in custody
c) Members of the Youth Offending Team did not all appear to appreciate that the Youth Offending Team could initiate a transfer within the secure estate
3. Caseworker based at Cookham Wood YOI
a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person
b) Although involved in the ACCT reviews the caseworker was unaware of the range of options available to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews
c) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release
Re: Cookham Wood YOI
1. Communication with outside agencies
a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person
2. ACCT
a) Officers were inconsistent in the recording of significant events; entries being made in either the wing observation log, ACCT ongoing record or not at all
b) At least one officer did not appear to appreciate the importance of significant incidents/disclosures or report them
c) Significant events in a lengthy ongoing record were not highlighted and therefore not obvious to officers reviewing safeguarding provisions
d) Officers were unaware of the need to involve outside agencies in the ACCT review process, the range of options available to them to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews
e) The safer regimes meetings were not provided with all relevant information and were not used to their full effect. The minutes of the meetings were not fully recorded
f) A holistic approach was not taken to the safe management of the young person during ACCT reviews or Safer Regimes meetings when it was apparent that he was struggling with the regime and that interventions were not working
3. Conflict between Regimes
a) Officers did not always seek advice before placing the young person on report for tattooing when there was an indication in the ACCT documentation that adjudication awards would lead to a heighted risk of self-harm
b) There was a conflict between the use of a behaviour improvement plan and adjudications which was not recognised at the time
4. Early Release
a) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release
5.Cell entry
a) There appeared to be an inflexible approach to cell entry requiring the presence of three prison officers even though YOI was in patrol state and concerns were sufficient to require entry
Re: Healthcare at Cookham Wood
NB: the service provider has changed since the death of Alex Kelly. The new provider is in the process of determining the systems and procedures being put in place at Cookham Wood
1. Sharing of Information
a) Officers concerned with the management of the young person were not informed in terms of his non-compliance with medication and the potential effect of the failure to take the medication
2. Medication management
a) a)Medication was found stockpiled in the young person’s cell; staff dispensing medication had not ensured it had been taken when it was probably recorded as having been taken
b) b)Any failure to take medication was not sufficiently flagged for healthcare/prison staff to deal with the issue
3.Recording of information
a) Not all occasions when the young person was seen by the in-reach team were recorded on System One
” Open source report
17 Dec 2014 Connor Steven Paul SMITH · Prevention of Future Deaths report Liverpool
View report summary
Concerns raised 1 Failure of investigations to verify the accuracy of relevant attendance records View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Connor Steven Paul SMITH · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Connor Steven Paul Smith, aged 20, died in custody at HMP Altcourse in the early hours of 2 January 2013 after being found hanging from a bed sheet; resuscitation was unsuccessful. The report identifies a concern about the quality of the PPO investigation, because a prison custody officer was recorded as attending a review hearing despite not being present, potentially hindering learning in another case.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure of investigations to verify the accuracy of relevant attendance records
Wider context from the report “On the 28th January 2013 the PPO investigator interviewed a PCO with regard to a review hearing under rule 49 - colloquially known as a rule 45 board. The officer was asked about the record of the meeting in which his name had appeared as an attendee. Given the frequency of such meetings the officer could not remember the meeting on the 1st January 2013 but was interviewed about it creating a 15 page transcript. On examination of other witnesses, other documentary evidence and a video of the meeting made it clear that the PCO was not present at the review hearing – his name had been entered on the Segregation Rule 45/Rule 49 Authority for continued segregation before the meeting but he had not been there.
This is an area of concern highlighting the quality of the investigation by the PPO where by such an error could in another case prevent lessons from being learnt.
” Open source report
Concerns raised 6 Lack of a set policy for when to call an ambulance View source Failure to properly check returned specialist investigation results View source Unclear and high threshold for recognising a medical emergency View source Failure to ensure necessary specialist investigations are recorded and carried out View source Inadequate training and clarity for night-time staff assessing medical emergencies View source Failure to consistently record and flag key healthcare events between daytime and night-time staff 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
GARRY GILBEY · 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
Garry Gilbey developed worsening arm, chest and breathing symptoms while imprisoned and was later diagnosed with inoperable lung cancer after being admitted to hospital on 25 June 2012. He died on 3 July 2012. The substantive concerns included unclear ambulance-call procedures and emergency thresholds for prison officers, inadequate communication of healthcare events to night staff, and failures to ensure that specialist investigations were arranged, completed and properly checked.
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 set policy for when to call an ambulance
Wider context from the report “1. The Prison did not have a set policy about when an ambulance should be called. This was left to the judgement of the prison officer(s) making an assessment of the prisoner from outside the cell and whether what they observed amounted to a medical emergency. In addition, it was not clear what amounted to a medical emergency and that the threshold was high. This raises genuine concern in relation to those prisoners who do not have 24/7 medically trained staff available to make emergency assessments of prisoners during the night.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to properly check returned specialist investigation results
Wider context from the report “4. There were also worrying aspects to prison health care systems including checking that all necessary specialist investigations are fully recorded and carried out as well as results properly checked when they return .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Unclear and high threshold for recognising a medical emergency
Wider context from the report “1. The Prison did not have a set policy about when an ambulance should be called. This was left to the judgement of the prison officer(s) making an assessment of the prisoner from outside the cell and whether what they observed amounted to a medical emergency. In addition, it was not clear what amounted to a medical emergency and that the threshold was high. This raises genuine concern in relation to those prisoners who do not have 24/7 medically trained staff available to make emergency assessments of prisoners during the night.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure necessary specialist investigations are recorded and carried out
Wider context from the report “4. There were also worrying aspects to prison health care systems including checking that all necessary specialist investigations are fully recorded and carried out as well as results properly checked when they return.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Inadequate training and clarity for night-time staff assessing medical emergencies
Wider context from the report “2. In turn this raises concern about the adequacy of training and clarity of what amounts to a medical emergency for those night time prison staff involved in having to make dynamic risk assessment especially for those prisoners who are at higher risk of a chronic condition developing into an acute episode e.g. during the referral period to a hospital especially when a very serious underlying condition is suspected such as lung cancer that has the capacity to affect breathing suddenly even though a prisoner may initially appear to be able to speak.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable 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 consistently record and flag key healthcare events between daytime and night-time staff
Wider context from the report “3. There was no clear or consistent system to flag key healthcare events during the day and there seemed to be a variable practice/policy in place that not all healthcare staff seemed to be familiar with or followed so that less relevant information was recorded such as an additional pillown being supplied yet important information such as nebuliser treatment or having a low threshold for medical review if symptoms reoccur or worsen was not consistently recorded in a way that would enable daytime medical staff to flag prisoner healthcare concerns to night-time prison staff.
” Open source report
27 Oct 2014 Chrylin Angela Maria Norrell-Goldsmith · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 4 Failure to retain complete primary source data within the Phoenix Programme View source Open and accessible ligature points within prisoner cells View source Failure to ensure multidisciplinary attendance or input at ACCT reviews View source Failure to record significant medical events in prisoner non-medical records accessible to discipline staff View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Chrylin Angela Maria Norrell-Goldsmith · 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
Chrylin Angela Maria Norrell-Goldsmith was found shortly before midnight on 26 July 2013, partially suspended by a ligature in her cell at HMP Downview. CPR and subsequent paramedic efforts were unsuccessful, and the jury concluded that she took her own life. The principal concerns included exposed pipework in the cell, multidisciplinary input at ACCT reviews, retention of primary source data in the Phoenix Programme, and recording significant medical events in records accessible to prison discipline staff.
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 retain complete primary source data within the Phoenix Programme
Wider context from the report “3. Retention of Primary Source Data within the Phoenix Programme
Consideration should be given to ensuring that all primary source data (ie data provided by the prisoner to the therapist), should be kept either in hard copy format or by way of faithfully recoding all the detail contained therein on the prisoner’s System One record .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Open and accessible ligature points within prisoner cells
Wider context from the report “1. Open pipe work within the cell
Whilst it may not be possible to remove all potential ligature points within a cell, removal of easily accessible and obvious ligature points may serve to reduce the risk of self harm and suicide to vulnerable prisoners .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure multidisciplinary attendance or input at ACCT reviews
Wider context from the report “2. Multi-Disciplinary Attendance / Input at ACCT Reviews
Consideration should be given to ensuring that all staff, including prison staff, healthcare staff and In Reach staff understand the importance of requiring and providing multi-disciplinary attendance, or alternatively, multi-disciplinary input at all ACCT reviews .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to record significant medical events in prisoner non-medical records accessible to discipline staff
Wider context from the report “4. Recording Significant Medical Events on a prisoner’s Non-medical Records
Consideration should be given to ensuring that all members of healthcare and In Reach staff working within a prison environment record all significant medical events that may impact upon a prisoner’s risk assessment for self-harm or suicide in a place or manner that is readily accessible to the discipline staff at the prison , in addition to any entry made in respect thereof in the System One record .
” Open source report
23 Oct 2014 Maria Christina Stubbings · Prevention of Future Deaths report Essex
View report summary
Concerns raised 5 Absence of a mechanism notifying local police when a person with a foreign murder conviction resides in their area View source Failure to ensure police awareness and protective conditions when individuals with foreign murder convictions enter the UK View source Exclusion of foreign murder convictions from the Notification Order framework View source Ineligibility of individuals with foreign murder convictions for a Violent Offender Order where the specified-offence risk threshold is not met View source Failure of the Central Authority to identify UK nationals serving sentences for serious crimes in EU prisons under the non-retrospective notification system 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
Maria Christina Stubbings · 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
Maria Christina Stubbings was murdered in December 2008 by a man who had previously served a life sentence in Germany for murder and had been arrested for assaulting her. The principal concerns relate to gaps in the identification, notification, monitoring and control of people with serious foreign convictions entering or residing in the UK.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Absence of a mechanism notifying local police when a person with a foreign murder conviction resides in their area
Wider context from the report “Notwithstanding the changes that have occurred (i) enabling a Violent Offender Order to be made in relation to someone who has a conviction for murder (including murder abroad) in May 2014 and (ii) the EU Directive which requires EU member states to notify the UK of foreign convictions of UK Nationals, at the time of conviction (as opposed to later than this which occurred in the ████████ case) and (iii) the electronic system now in place at the Central Authority – it seems that there are further opportunities that might be considered which would reduce the likelihood of another individual (with a murder conviction like ████████) entering the UK without conditions and without any police force being made aware of that person’s existence, until arrested for different offence.
I ask the Home Office/MoJ to give consideration to further steps that could be taken to address the issues, including those detailed below. In making the suggestion below it is recognised that the issues are complex.
(i) The Central Authority needs to be notified now of all EU nationals currently serving a sentence for serious crimes such as murder in those countries. We understand the new notification system which obliges an EU state to notify at the time of conviction, is not retrospective. Accordingly, there are likely to be a pool of older prisoners who are UK nationals, serving sentences in EU prisons, which the Central Authority is not yet aware of. Further consideration could be given to making a request of each country in order to identify who these individuals are and the offences for which they have been convicted;
(ii) Consideration could be given to some form of “warning marker” which could be placed on an individual’s passport which would alert the authorities to the entry of a UK national convicted of murder, back into the UK. Furthermore, it might be possible for the Immigration Rules to be amended to enable a passport officer to request details from that individual as to the address they are going to stay at in UK; details of any car to be used by them; details of relatives; people they intend to stay with etc. The police are aware from the evidence disclosed in the Inquest (notably pre-sentence reports on ████████ that he was told by the German authorities upon his deportation that he would be met by Security Officers in the UK, who would ensure that he was given advice and keep an eye on him. It appears that this did not happen and he was free to enter the UK at Heathrow airport of 24th January, 2008 and met his father who was waiting for him;
(iii) Consideration needs to be given to putting in place a mechanism which notifies local police that someone with a conviction like the murder conviction ████████ has come to reside in their area .
(iv) There could be an amendment to allow for a Notification Orders to be applied for. The principle response of the Home Office/MoJ was to amend the law to allow for the police to apply for the Violent Offender Order (VOO) However, as you are aware such orders will only be granted if there is a risk that the individual is likely to commit one of more of the specified offences in Section 98(3) of the Criminal Justice and Immigration Act 2008. Those offences are 6 types of serious violent offences from Section 20 OAPA 1861 upwards to manslaughter.
It is doubtful that a VOO would have been granted in the case of ████████ following the incident in July 2008, as he had only been convicted of the offence of common assault and the circumstances of the sexual offence left on file would not be relevant.
(v) It may be possible for an amendment to be made to Schedule 3 of the Sexual Offences Act 2003 to include a foreign conviction for murder. With the benefit of hindsight this would allow the police to have applied for a Notification Order against ████████ as soon as they were aware of his existence. This would require him to comply with the notification requirements under section 83(5) of that Act requiring him to state his date of birth; national insurance number; home address and specify any address at which he stays on a periodic basis. It would be a useful mechanism to monitor an individual’s movements when no licence conditions would apply.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable 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 police awareness and protective conditions when individuals with foreign murder convictions enter the UK
Wider context from the report “Notwithstanding the changes that have occurred (i) enabling a Violent Offender Order to be made in relation to someone who has a conviction for murder (including murder abroad) in May 2014 and (ii) the EU Directive which requires EU member states to notify the UK of foreign convictions of UK Nationals, at the time of conviction (as opposed to later than this which occurred in the ████████ case) and (iii) the electronic system now in place at the Central Authority – it seems that there are further opportunities that might be considered which would reduce the likelihood of another individual (with a murder conviction like ████████) entering the UK without conditions and without any police force being made aware of that person’s existence , until arrested for different offence.
I ask the Home Office/MoJ to give consideration to further steps that could be taken to address the issues, including those detailed below. In making the suggestion below it is recognised that the issues are complex.
(i) The Central Authority needs to be notified now of all EU nationals currently serving a sentence for serious crimes such as murder in those countries. We understand the new notification system which obliges an EU state to notify at the time of conviction, is not retrospective. Accordingly, there are likely to be a pool of older prisoners who are UK nationals, serving sentences in EU prisons, which the Central Authority is not yet aware of. Further consideration could be given to making a request of each country in order to identify who these individuals are and the offences for which they have been convicted;
(ii) Consideration could be given to some form of “warning marker” which could be placed on an individual’s passport which would alert the authorities to the entry of a UK national convicted of murder, back into the UK. Furthermore, it might be possible for the Immigration Rules to be amended to enable a passport officer to request details from that individual as to the address they are going to stay at in UK; details of any car to be used by them; details of relatives; people they intend to stay with etc. The police are aware from the evidence disclosed in the Inquest (notably pre-sentence reports on ████████ that he was told by the German authorities upon his deportation that he would be met by Security Officers in the UK, who would ensure that he was given advice and keep an eye on him. It appears that this did not happen and he was free to enter the UK at Heathrow airport of 24th January, 2008 and met his father who was waiting for him;
(iii) Consideration needs to be given to putting in place a mechanism which notifies local police that someone with a conviction like the murder conviction ████████ has come to reside in their area.
(iv) There could be an amendment to allow for a Notification Orders to be applied for. The principle response of the Home Office/MoJ was to amend the law to allow for the police to apply for the Violent Offender Order (VOO) However, as you are aware such orders will only be granted if there is a risk that the individual is likely to commit one of more of the specified offences in Section 98(3) of the Criminal Justice and Immigration Act 2008. Those offences are 6 types of serious violent offences from Section 20 OAPA 1861 upwards to manslaughter.
It is doubtful that a VOO would have been granted in the case of ████████ following the incident in July 2008, as he had only been convicted of the offence of common assault and the circumstances of the sexual offence left on file would not be relevant.
(v) It may be possible for an amendment to be made to Schedule 3 of the Sexual Offences Act 2003 to include a foreign conviction for murder. With the benefit of hindsight this would allow the police to have applied for a Notification Order against ████████ as soon as they were aware of his existence. This would require him to comply with the notification requirements under section 83(5) of that Act requiring him to state his date of birth; national insurance number; home address and specify any address at which he stays on a periodic basis. It would be a useful mechanism to monitor an individual’s movements when no licence conditions would apply.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Exclusion of foreign murder convictions from the Notification Order framework
Wider context from the report “Notwithstanding the changes that have occurred (i) enabling a Violent Offender Order to be made in relation to someone who has a conviction for murder (including murder abroad) in May 2014 and (ii) the EU Directive which requires EU member states to notify the UK of foreign convictions of UK Nationals, at the time of conviction (as opposed to later than this which occurred in the ████████ case) and (iii) the electronic system now in place at the Central Authority – it seems that there are further opportunities that might be considered which would reduce the likelihood of another individual (with a murder conviction like ████████) entering the UK without conditions and without any police force being made aware of that person’s existence, until arrested for different offence.
I ask the Home Office/MoJ to give consideration to further steps that could be taken to address the issues, including those detailed below. In making the suggestion below it is recognised that the issues are complex.
(i) The Central Authority needs to be notified now of all EU nationals currently serving a sentence for serious crimes such as murder in those countries. We understand the new notification system which obliges an EU state to notify at the time of conviction, is not retrospective. Accordingly, there are likely to be a pool of older prisoners who are UK nationals, serving sentences in EU prisons, which the Central Authority is not yet aware of. Further consideration could be given to making a request of each country in order to identify who these individuals are and the offences for which they have been convicted;
(ii) Consideration could be given to some form of “warning marker” which could be placed on an individual’s passport which would alert the authorities to the entry of a UK national convicted of murder, back into the UK. Furthermore, it might be possible for the Immigration Rules to be amended to enable a passport officer to request details from that individual as to the address they are going to stay at in UK; details of any car to be used by them; details of relatives; people they intend to stay with etc. The police are aware from the evidence disclosed in the Inquest (notably pre-sentence reports on ████████ that he was told by the German authorities upon his deportation that he would be met by Security Officers in the UK, who would ensure that he was given advice and keep an eye on him. It appears that this did not happen and he was free to enter the UK at Heathrow airport of 24th January, 2008 and met his father who was waiting for him;
(iii) Consideration needs to be given to putting in place a mechanism which notifies local police that someone with a conviction like the murder conviction ████████ has come to reside in their area.
(iv) There could be an amendment to allow for a Notification Orders to be applied for. The principle response of the Home Office/MoJ was to amend the law to allow for the police to apply for the Violent Offender Order (VOO) However, as you are aware such orders will only be granted if there is a risk that the individual is likely to commit one of more of the specified offences in Section 98(3) of the Criminal Justice and Immigration Act 2008. Those offences are 6 types of serious violent offences from Section 20 OAPA 1861 upwards to manslaughter.
It is doubtful that a VOO would have been granted in the case of ████████ following the incident in July 2008, as he had only been convicted of the offence of common assault and the circumstances of the sexual offence left on file would not be relevant.
(v) It may be possible for an amendment to be made to Schedule 3 of the Sexual Offences Act 2003 to include a foreign conviction for murder . With the benefit of hindsight this would allow the police to have applied for a Notification Order against ████████ as soon as they were aware of his existence. This would require him to comply with the notification requirements under section 83(5) of that Act requiring him to state his date of birth; national insurance number; home address and specify any address at which he stays on a periodic basis. It would be a useful mechanism to monitor an individual’s movements when no licence conditions would apply .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Ineligibility of individuals with foreign murder convictions for a Violent Offender Order where the specified-offence risk threshold is not met
Wider context from the report “Notwithstanding the changes that have occurred (i) enabling a Violent Offender Order to be made in relation to someone who has a conviction for murder (including murder abroad) in May 2014 and (ii) the EU Directive which requires EU member states to notify the UK of foreign convictions of UK Nationals, at the time of conviction (as opposed to later than this which occurred in the ████████ case) and (iii) the electronic system now in place at the Central Authority – it seems that there are further opportunities that might be considered which would reduce the likelihood of another individual (with a murder conviction like ████████) entering the UK without conditions and without any police force being made aware of that person’s existence, until arrested for different offence.
I ask the Home Office/MoJ to give consideration to further steps that could be taken to address the issues, including those detailed below. In making the suggestion below it is recognised that the issues are complex.
(i) The Central Authority needs to be notified now of all EU nationals currently serving a sentence for serious crimes such as murder in those countries. We understand the new notification system which obliges an EU state to notify at the time of conviction, is not retrospective. Accordingly, there are likely to be a pool of older prisoners who are UK nationals, serving sentences in EU prisons, which the Central Authority is not yet aware of. Further consideration could be given to making a request of each country in order to identify who these individuals are and the offences for which they have been convicted;
(ii) Consideration could be given to some form of “warning marker” which could be placed on an individual’s passport which would alert the authorities to the entry of a UK national convicted of murder, back into the UK. Furthermore, it might be possible for the Immigration Rules to be amended to enable a passport officer to request details from that individual as to the address they are going to stay at in UK; details of any car to be used by them; details of relatives; people they intend to stay with etc. The police are aware from the evidence disclosed in the Inquest (notably pre-sentence reports on ████████ that he was told by the German authorities upon his deportation that he would be met by Security Officers in the UK, who would ensure that he was given advice and keep an eye on him. It appears that this did not happen and he was free to enter the UK at Heathrow airport of 24th January, 2008 and met his father who was waiting for him;
(iii) Consideration needs to be given to putting in place a mechanism which notifies local police that someone with a conviction like the murder conviction ████████ has come to reside in their area.
(iv) There could be an amendment to allow for a Notification Orders to be applied for. The principle response of the Home Office/MoJ was to amend the law to allow for the police to apply for the Violent Offender Order (VOO) However, as you are aware such orders will only be granted if there is a risk that the individual is likely to commit one of more of the specified offences in Section 98(3) of the Criminal Justice and Immigration Act 2008. Those offences are 6 types of serious violent offences from Section 20 OAPA 1861 upwards to manslaughter.
It is doubtful that a VOO would have been granted in the case of ████████ following the incident in July 2008, as he had only been convicted of the offence of common assault and the circumstances of the sexual offence left on file would not be relevant.
(v) It may be possible for an amendment to be made to Schedule 3 of the Sexual Offences Act 2003 to include a foreign conviction for murder. With the benefit of hindsight this would allow the police to have applied for a Notification Order against ████████ as soon as they were aware of his existence. This would require him to comply with the notification requirements under section 83(5) of that Act requiring him to state his date of birth; national insurance number; home address and specify any address at which he stays on a periodic basis. It would be a useful mechanism to monitor an individual’s movements when no licence conditions would apply.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable 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 Central Authority to identify UK nationals serving sentences for serious crimes in EU prisons under the non-retrospective notification system
Wider context from the report “Notwithstanding the changes that have occurred (i) enabling a Violent Offender Order to be made in relation to someone who has a conviction for murder (including murder abroad) in May 2014 and (ii) the EU Directive which requires EU member states to notify the UK of foreign convictions of UK Nationals, at the time of conviction (as opposed to later than this which occurred in the ████████ case) and (iii) the electronic system now in place at the Central Authority – it seems that there are further opportunities that might be considered which would reduce the likelihood of another individual (with a murder conviction like ████████) entering the UK without conditions and without any police force being made aware of that person’s existence, until arrested for different offence.
I ask the Home Office/MoJ to give consideration to further steps that could be taken to address the issues, including those detailed below. In making the suggestion below it is recognised that the issues are complex.
(i) The Central Authority needs to be notified now of all EU nationals currently serving a sentence for serious crimes such as murder in those countries. We understand the new notification system which obliges an EU state to notify at the time of conviction, is not retrospective. Accordingly, there are likely to be a pool of older prisoners who are UK nationals, serving sentences in EU prisons, which the Central Authority is not yet aware of . Further consideration could be given to making a request of each country in order to identify who these individuals are and the offences for which they have been convicted;
(ii) Consideration could be given to some form of “warning marker” which could be placed on an individual’s passport which would alert the authorities to the entry of a UK national convicted of murder, back into the UK. Furthermore, it might be possible for the Immigration Rules to be amended to enable a passport officer to request details from that individual as to the address they are going to stay at in UK; details of any car to be used by them; details of relatives; people they intend to stay with etc. The police are aware from the evidence disclosed in the Inquest (notably pre-sentence reports on ████████ that he was told by the German authorities upon his deportation that he would be met by Security Officers in the UK, who would ensure that he was given advice and keep an eye on him. It appears that this did not happen and he was free to enter the UK at Heathrow airport of 24th January, 2008 and met his father who was waiting for him;
(iii) Consideration needs to be given to putting in place a mechanism which notifies local police that someone with a conviction like the murder conviction ████████ has come to reside in their area.
(iv) There could be an amendment to allow for a Notification Orders to be applied for. The principle response of the Home Office/MoJ was to amend the law to allow for the police to apply for the Violent Offender Order (VOO) However, as you are aware such orders will only be granted if there is a risk that the individual is likely to commit one of more of the specified offences in Section 98(3) of the Criminal Justice and Immigration Act 2008. Those offences are 6 types of serious violent offences from Section 20 OAPA 1861 upwards to manslaughter.
It is doubtful that a VOO would have been granted in the case of ████████ following the incident in July 2008, as he had only been convicted of the offence of common assault and the circumstances of the sexual offence left on file would not be relevant.
(v) It may be possible for an amendment to be made to Schedule 3 of the Sexual Offences Act 2003 to include a foreign conviction for murder. With the benefit of hindsight this would allow the police to have applied for a Notification Order against ████████ as soon as they were aware of his existence. This would require him to comply with the notification requirements under section 83(5) of that Act requiring him to state his date of birth; national insurance number; home address and specify any address at which he stays on a periodic basis. It would be a useful mechanism to monitor an individual’s movements when no licence conditions would apply.
” Open source report
Concerns raised 4 Lack of standards and objectively assessed qualifications for assessing stray dogs’ suitability for re-homing View source Lack of standards for assessing potential applicants’ suitability and home circumstances when re-homing a dog View source Lack of independent verification of kennels’ dog re-homing policies and their implementation View source Lack of national or local standards for judging stray dog re-homing policies View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Lexi Branson · 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
Lexi Branson, aged 4¾ years, died after a dog attacked her in the living room of her home, causing extensive neck and facial injuries and preventing breathing. The report identified concerns about the absence of national or local standards for re-homing stray dogs, assessing dogs and applicants, and independently verifying kennel policies and their implementation.
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 standards and objectively assessed qualifications for assessing stray dogs’ suitability for re-homing
Wider context from the report “The following concerns became clear as a result of the evidence which I heard:
(1) There are no national or local standards by which any policy for the re-homing of stray dogs is to be judged;
(2) There are no national or local standards for the assessment of the suitability of stray dogs for re-homing and, at present, no requirement for any objectively-assessed qualifications which are required to be obtained by those making any assessments ;
(3) There are no national or local standards for assessing the suitability and home circumstances of potential applicants applying to re-home a dog.
(4) There is no independent verification of the policies which kennels may have for the re-homing of dogs nor of their implementation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 standards for assessing potential applicants’ suitability and home circumstances when re-homing a dog
Wider context from the report “The following concerns became clear as a result of the evidence which I heard:
(1) There are no national or local standards by which any policy for the re-homing of stray dogs is to be judged;
(2) There are no national or local standards for the assessment of the suitability of stray dogs for re-homing and, at present, no requirement for any objectively-assessed qualifications which are required to be obtained by those making any assessments;
(3) There are no national or local standards for assessing the suitability and home circumstances of potential applicants applying to re-home a dog .
(4) There is no independent verification of the policies which kennels may have for the re-homing of dogs nor of their implementation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 verification of kennels’ dog re-homing policies and their implementation
Wider context from the report “The following concerns became clear as a result of the evidence which I heard:
(1) There are no national or local standards by which any policy for the re-homing of stray dogs is to be judged;
(2) There are no national or local standards for the assessment of the suitability of stray dogs for re-homing and, at present, no requirement for any objectively-assessed qualifications which are required to be obtained by those making any assessments;
(3) There are no national or local standards for assessing the suitability and home circumstances of potential applicants applying to re-home a dog.
(4) There is no independent verification of the policies which kennels may have for the re-homing of dogs nor of their implementation .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Lack of national or local standards for judging stray dog re-homing policies
Wider context from the report “The following concerns became clear as a result of the evidence which I heard:
(1) There are no national or local standards by which any policy for the re-homing of stray dogs is to be judged ;
(2) There are no national or local standards for the assessment of the suitability of stray dogs for re-homing and, at present, no requirement for any objectively-assessed qualifications which are required to be obtained by those making any assessments;
(3) There are no national or local standards for assessing the suitability and home circumstances of potential applicants applying to re-home a dog.
(4) There is no independent verification of the policies which kennels may have for the re-homing of dogs nor of their implementation.
” Open source report
29 Aug 2014 Stephen Philip Owen Farrar · Prevention of Future Deaths report Milton Keynes
View report summary
Concerns raised 2 Failure to complete formal self-harm or suicide risk assessments on prison admission View source Unavailability of a formal self-harm or suicide risk assessment tool in prisons 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 Philip Owen Farrar · 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 Philip Owen Farrar was found hanging in his cell at HMP Woodhill on 12 December 2013 and was pronounced dead later that evening. The report raised concerns that no formal self-harm or suicide risk assessment had been completed on admission despite his previous self-harm history and past mental health problems, and that no formal risk assessment tool was available in prisons.
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 formal self-harm or suicide risk assessments on prison admission
Wider context from the report “[BRIEF SUMMARY OF MATTERS OF CONCERN]
(1)That when Mr Farrar was first admitted to Woodhill Prison there was formal risk assessment completed as to the risk of self harm or suicide despite the fact that he was under the age of 30,was returning to prison, had a history of previous self harm, and had mental health problems in the past including depression . Almost any risk assessment tool would have identified him as high risk.
(2) I was told that there is no formal risk assessment tool available in any of our prisons.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Unavailability of a formal self-harm or suicide risk assessment tool in prisons
Wider context from the report “[BRIEF SUMMARY OF MATTERS OF CONCERN]
(1)That when Mr Farrar was first admitted to Woodhill Prison there was formal risk assessment completed as to the risk of self harm or suicide despite the fact that he was under the age of 30,was returning to prison, had a history of previous self harm, and had mental health problems in the past including depression. Almost any risk assessment tool would have identified him as high risk.
(2) I was told that there is no formal risk assessment tool available in any of our prisons .
” Open source report
8 Aug 2014 Sean Robert Brock · Prevention of Future Deaths report Milton Keynes
View report summary
Concerns raised 1 Insufficient prison officer staffing at HMP Woodhill 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
Sean Robert Brock · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Sean Brock died by hanging in his prison cell at Woodhill Prison on 10 November 2013, during his fourth day in prison and his first time in an adult high-security prison. The report raised concern that a one-third reduction in prison officer numbers could compromise prison safety and put prisoner lives at risk.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Insufficient prison officer staffing at HMP Woodhill
Wider context from the report “A Governor from the prison during his evidence informed me that the number of prison officers at HMP Woodhill had been reduced by one third . The reduction in numbers will in his view compromise prison safety and may put prisoner lives at risk .
” Open source report
30 Jun 2014 Jake Reginald Hardy · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 12 Failure to provide detainees with the benefit and protection of a Personal Officer View source Insufficient staff understanding of vulnerable young persons’ complex needs and their causes View source Lack of a system for timely telephone contact with family during crisis or emotional need View source Night-time verbal bullying increasing self-harm and suicide risk among targeted detainees View source Unavailability of private telephone communication for detained children and young persons View source Increased risk of self-harm and suicide among vulnerable detainees with complex needs placed in Youth Offender Institutions View source Use of cells containing ligature points for detainees at risk of self-harm or suicide View source Lack of consideration of adopting safeguarding policy and procedure changes across Youth Offender Institutions View source Lack of understanding and performance oversight of Personal Officer obligations View source Insufficient staff aptitude or temperamential suitability for working with vulnerable young persons with complex needs View source Lack of a reliable system for recording and reading important wing information and outstanding tasks during Senior Officer handover View source Lack of an effective system to routinely monitor and tackle night-time verbal bullying View source See 9 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Jake Reginald Hardy · 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
Jake Reginald Hardy, a 17-year-old detained at HM YOI Hindley, died on 20 January 2012 after being found partially suspended by a ligature in his cell. The report describes failures to identify, record and respond to his vulnerabilities, self-harm risk and reports of verbal bullying, including failures in safeguarding, ACCT care planning, supervision and overnight risk assessment. Concerns also included ligature points in cells, inadequate personal officer support, staff training and communication systems, and limited access to family telephone support.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to provide detainees with the benefit and protection of a Personal Officer
Wider context from the report “2. The evidence revealed an almost complete failure to provide Jake Hardy with the benefit and protection of a Personal Officer , despite a comprehensive scheme being in place. Currently the scheme is of pivotal importance for the identification and monitoring of vulnerability and risk .
There remains a concern about whether all officers at HM YOI Hindley have a sufficient understanding of this role and its importance and about the absence of any system to alert managers to any failure by a Personal Officer to meet his obligations under this scheme or to audit his performance. This concern may be of relevance to other Young Offender Institutes also.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 staff understanding of vulnerable young persons’ complex needs and their causes
Wider context from the report “1. A number of the prison staff from HM YOI Hindley who gave evidence at the inquest clearly lacked (a) any or sufficient aptitude or temperamential suitability for the demands of working with vulnerable young persons with complex needs and/or (b) any or sufficient understanding of those needs and their causes (such as the nature and effect of specific learning difficulties and the effect of abuse or neglect in childhood).
I have been told that these matters are now addressed to some extent by the Youth Justice Board and HM YOI Hindley but that further changes are being considered to the way in which prison staff working in Young Offender Institutes are recruited, screened for aptitude and trained . I report this concern so that any outstanding further steps can 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 Lack of a system for timely telephone contact with family during crisis or emotional need
Wider context from the report “5. The children and young persons detained at HM YOI Hindley are provided with a weekly credit which they may use to telephone family or other approved numbers. Calls are made from a communal telephone located in the association area of a wing. Prison staff have a discretion to permit further calls to be made from an office telephone for good reason.
I was told that in-cell telephony has been introduced in newly built parts of the children and young persons’ estate but it is not available in HM YOI Hindley and other Young Offender Institutes. Currently, therefore, these detainees are not able to speak privately on the telephone and there is no sufficient system in place to ensure that a child or young person in crisis or in need of emotional support (whether by reason of being bullied or experiencing feelings of self-harm or suicide) can speak to a family member without significant delay.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Night-time verbal bullying increasing self-harm and suicide risk among targeted detainees
Wider context from the report “4. Verbal bullying by means of detainees “shouting out” at night is a common problem in HM YOI Hindley and can increase the risk of self-harm and suicide by those targeted , especially overnight. The fabric, lay-out and design of the cells in HM YOI Hindley does not remedy this problem. Further, it is difficult for the night orderly officer on duty on a wing, who is there alone, to tackle the problem effectively. There is no effective system in place to ensure that the problem is routinely monitored and tackled effectively, whether by means of additional staff or otherwise. This concern may be of relevance to other Young Offender Institutes also.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 private telephone communication for detained children and young persons
Wider context from the report “5. The children and young persons detained at HM YOI Hindley are provided with a weekly credit which they may use to telephone family or other approved numbers. Calls are made from a communal telephone located in the association area of a wing. Prison staff have a discretion to permit further calls to be made from an office telephone for good reason.
I was told that in-cell telephony has been introduced in newly built parts of the children and young persons’ estate but it is not available in HM YOI Hindley and other Young Offender Institutes. Currently, therefore, these detainees are not able to speak privately on the telephone and there is no sufficient system in place to ensure that a child or young person in crisis or in need of emotional support (whether by reason of being bullied or experiencing feelings of self-harm or suicide) can speak to a family member without significant delay.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Increased risk of self-harm and suicide among vulnerable detainees with complex needs placed in Youth Offender Institutions
Wider context from the report “1. It was apparent from the evidence I heard that a significant proportion of the children and young persons placed in HM YOI Hindley are vulnerable and have complex needs. This may well be true of the children and young persons placed in other Youth Offender Institutions also.
Clearly, the nature and extent of Jake Hardy’s vulnerabilities were not unusual amongst this population, with many detainees having some form of learning difficulty. I was told that other detainees are vulnerable for different reasons, for example because they have been abused or neglected or their upbringing has been adversely affected by a parent’s misuse of alcohol or drugs. Many are “looked after children”. I was also told that these detainees “complexities affect their reaction to authority and boundaries and are probably the reason they ended up in custody in the first place”.
It was also apparent that vulnerable detainees are likely to lack the emotional and intellectual maturity and resilience they may need to cope with the pressures of life in custody (such as separation from family and bullying) and that the risk of self-harm and suicide can increase in consequence. I was told that safeguarding these detainees is made more difficult by the prevalence of their volatile and unpredictable behaviour.
Overall, the evidence suggested that the placement of vulnerable children and young persons with complex needs in the environment of a Youth Offender Institute (particularly if some distance from home) does, in some cases, result in an increased risk of self-harm and suicide which it is often difficult for prison and clinical staff to manage effectively , even with the benefit of the various policies and procedures which are in place.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Use of cells containing ligature points for detainees at risk of self-harm or suicide
Wider context from the report “3. Cells containing ligature points (such as window bars) are still in use at HM YOI Hindley for detainees who have been assessed to be at risk of self-harm or suicide . This concern may be of relevance to other Young Offender Institutes also.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 consideration of adopting safeguarding policy and procedure changes across Youth Offender Institutions
Wider context from the report “2. As stated above, significant changes of policy and procedure have been introduced at HM YOI Hindley in order to address concerns raised about the identification, monitoring and protection of vulnerable children and young persons and those at risk of self-harm and suicide. It may well be that some or all of those changes would provide better protection to detainees in other Young Offender Institutes but I am not aware that consideration has been given to the adoption of these changes elsewhere in the estate .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding and performance oversight of Personal Officer obligations
Wider context from the report “2. The evidence revealed an almost complete failure to provide Jake Hardy with the benefit and protection of a Personal Officer, despite a comprehensive scheme being in place. Currently the scheme is of pivotal importance for the identification and monitoring of vulnerability and risk.
There remains a concern about whether all officers at HM YOI Hindley have a sufficient understanding of this role and its importance and about the absence of any system to alert managers to any failure by a Personal Officer to meet his obligations under this scheme or to audit his performance . This concern may be of relevance to other Young Offender Institutes also.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 staff aptitude or temperamential suitability for working with vulnerable young persons with complex needs
Wider context from the report “1. A number of the prison staff from HM YOI Hindley who gave evidence at the inquest clearly lacked (a) any or sufficient aptitude or temperamential suitability for the demands of working with vulnerable young persons with complex needs and/or (b) any or sufficient understanding of those needs and their causes (such as the nature and effect of specific learning difficulties and the effect of abuse or neglect in childhood).
I have been told that these matters are now addressed to some extent by the Youth Justice Board and HM YOI Hindley but that further changes are being considered to the way in which prison staff working in Young Offender Institutes are recruited, screened for aptitude and trained. I report this concern so that any outstanding further steps can 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 Lack of a reliable system for recording and reading important wing information and outstanding tasks during Senior Officer handover
Wider context from the report “6. The shift patterns of Senior Officers working on the wings within HM YOI Hindley are such that they do not always overlap and handover is often by means of written entries in a “handover book”. The handover book I saw contained short notes addressing random matters and there was apparently no routine recording of a more comprehensive review of the shift. There is no system in place to ensure that important information and outstanding tasks are sufficiently recorded by one Senior Officer at the end of his shift and then read by the next Senior Officer at the start of his shift .
It was clear from the evidence that it is the Senior Officer’s responsibility to have an overview of what is happening on the wing and matters of relevance to the safeguarding of detainees housed there. Therefore, the passing of key information and outstanding tasks between Senior Officers on a wing is of real importance to the safety of detainees. This concern may be of relevance to other Young Offender Institutes also.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Lack of an effective system to routinely monitor and tackle night-time verbal bullying
Wider context from the report “4. Verbal bullying by means of detainees “shouting out” at night is a common problem in HM YOI Hindley and can increase the risk of self-harm and suicide by those targeted, especially overnight. The fabric, lay-out and design of the cells in HM YOI Hindley does not remedy this problem. Further, it is difficult for the night orderly officer on duty on a wing, who is there alone, to tackle the problem effectively. There is no effective system in place to ensure that the problem is routinely monitored and tackled effectively , whether by means of additional staff or otherwise. This concern may be of relevance to other Young Offender Institutes also.
” Open source report
20 Jun 2014 Redmond Johnson · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 7 Delays in delivering transfer information needed for fitness assessment View source Failure to identify and rebook outstanding healthcare appointments View source Lack of a robust documented process for assessing fitness to transfer View source Failure to arrange medication for periods when detainees are out of prison care View source Failure to obtain relevant medical information for care planning during initial reception assessment View source Failure to conduct medication reviews for complex medication issues View source Inadequate documentation confirming completion and clinical review of requested investigations View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Redmond Johnson · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Redmond Johnson, aged 67, suffered a cardio-respiratory arrest while being transferred to Ipswich Crown Court on 25 November 2011 and died after transfer to Ipswich Hospital. The report identified concerns about the assessment of his fitness for transfer, including a record stating that he had no known medical risks despite the healthcare professional not having seen him. It also identified concerns about the management and documentation of his complex healthcare needs in custody, including liaison with community providers, specialist appointments, investigations, medication and care monitoring.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Delays in delivering transfer information needed for fitness assessment
Wider context from the report “(6) Information about which detainees are going to be transferred to court or other locations needs to be delivered to the individual prisons in enough time for a thorough assessment of the detainee’s fitness to be transferred (including a face to face assessment if required) to be conducted.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to identify and rebook outstanding healthcare appointments
Wider context from the report “(2) Reception healthcare should ask about any outstanding hospital or other healthcare appointments and rebook those if necessary .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Lack of a robust documented process for assessing fitness to transfer
Wider context from the report “(5) There must be a robust and clearly documented process in place when assessing a detainee’s fitness to transfer , together with clear arrangements made in respect of any medication that the detainee needs to take while out of the prison’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 arrange medication for periods when detainees are out of prison care
Wider context from the report “(5) There must be a robust and clearly documented process in place when assessing a detainee’s fitness to transfer, together with clear arrangements made in respect of any medication that the detainee needs to take while out of the prison’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 obtain relevant medical information for care planning during initial reception assessment
Wider context from the report “(1) If a detainee has a history of significant medical problems, healthcare professionals undertaking the initial reception assessment should request further information from the General Practitioner and, where necessary, hospital doctors normally involved in the detainee’s care to enable appropriate care planning while that detainee is in the custody of the prison service.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable 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 medication reviews for complex medication issues
Wider context from the report “(3) Medication reviews should be conducted, with appropriate pharmacy input if required, if there are complex medication issues that need resolving or clarifying .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 documentation confirming completion and clinical review of requested investigations
Wider context from the report “(4) If medical tests or investigations are requested, there must be clear and adequate documentation to confirm that those investigations have actually been conducted and the results seen by a healthcare professional .
” Open source report
Concerns raised 3 Unclear process for promptly obtaining community mental health records View source Failure to ensure ACCT health-screening doctors are trained in required procedures View source Failure to provide sufficient ACCT trigger-event recording and assessment guidance for objective risk assessment View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Matthew Thomas Purser · 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 Thomas Purser hanged himself in his cell at Swansea Prison on 13 June 2012, after being remanded there and placed on self-harm monitoring. The report identified concerns about inadequate ACCT training, insufficiently objective recording and review of trigger events and significant interactions, and unclear arrangements for obtaining community mental health records.
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 Unclear process for promptly obtaining community mental health records
Wider context from the report “3. The prison appreciated that Mr. Purser was due to have a psychiatrist’s appointment in the community soon after coming into prison. Although he was booked into the primary care prison mental health service the means by which community health records were to be obtained was not clear . For an appropriate assessment to be made there is a need for an urgent contact with community mental health services to be made so that records are promptly obtained .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable 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 ACCT health-screening doctors are trained in required procedures
Wider context from the report “1. The Doctor who saw Mr. Purser for the second health screen on the day after admission had not received ACCT training as required by PS 164/2011 and HMP Swansea Suicide Prevention Policy 2010 and was not aware of the requirement for him to be trained in the procedures .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable 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 sufficient ACCT trigger-event recording and assessment guidance for objective risk assessment
Wider context from the report “2. The trigger event endorsed on the documentation requiring review of Mr. Purser under the ACCT was given as “loss of contact with partner/breakdown in relationship”. Mr. Purser’s apparent dependence on maintaining contact with his partner was correctly identified by the prison but the way in which the wording of the trigger was expressed left much to the subjective assessment of the officers about the state of his relationship with his partner. Because of the way in which the ACCT records were kept officers did not have enough information to make a realistic assessment and in their evidence some officers draw a distinction between Mr. Purser’s relationship going through a difficult time and it having broken down. If a trigger event is something which cannot be easily and objectively determined by an officer more detailed observations and recording will be required . If the only way in which a trigger can be expressed is in similar language to the trigger some indication needs to be given as to how the assessment is to be carried out and how clearly information must be shared by means of the records kept .
” Open source report
26 Feb 2014 Hazel Claire Polkinghorn · Prevention of Future Deaths report Central Lincolnshire
View report summary
Concerns raised 1 Ease of acquiring potentially dangerous non-prescribed medication from internet websites 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
Hazel Claire Polkinghorn · 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
Hazel Claire Polkinghorn, who had a history of mental health difficulties, was found deceased in her flat on 24 April 2013 after taking an overdose of Pentobarbital acquired from the internet. The principal concern was the ease with which she obtained potentially dangerous non-prescribed medication online and the risk of similar deaths unless such websites were screened and closed down.
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 Ease of acquiring potentially dangerous non-prescribed medication from internet websites
Wider context from the report “Miss Polkinghorn acquired non prescribed medication from the internet. She took an overdose of the drugs so acquired and died on the 24th April 2013. I am deeply concerned regarding the ease with which Miss Polkinghorn managed to acquire Pentobarbital (and other medication) from the internet . I am particularly concerned that other similar deaths will occur unless steps are taken by Central Government to screen and close down websites such as this which are engaged in selling potentially dangerous non prescribed medication .
” Open source report
25 Feb 2014 Lee Terence Curran · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 6 Failure to fully investigate prisoners’ reported episodes of loss of consciousness View source Failure to conduct NICE-compliant investigations of loss of consciousness View source Failure to make accurate and evidentially grounded entries in prisoners’ medical notes View source Failure to conduct clinical investigations of prisoners experiencing loss of consciousness View source Failure to take full account of family history when clinically investigating prisoners with possible high cholesterol View source Lack of doctors’ awareness of NICE guidelines for transient loss of consciousness 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
Lee Terence Curran · 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 Terence Curran died on 3 May 2011 while in custody at Forest Bank Prison, with naturally occurring ischaemic heart disease identified as the prime cause of death. Before his death, he experienced multiple episodes of transient loss of consciousness that were not diagnosed, and concerns were raised that recommended investigations and follow-up were not provided. Further concerns included incomplete implementation of recommendations, potentially misleading medical-note entries, and inadequate awareness or application of relevant clinical guidelines.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to fully investigate prisoners’ reported episodes of loss of consciousness
Wider context from the report “(3) Evidence given at the Inquest also revealed a need for the training of Doctors working in prisons in that Doctors who provided general practice sessions at the prison (and in the community) gave evidence that they were unaware of the NICE Guidelines for Transient Loss of Consciousness Management in Adults and Young People despite such episodes being common in a prison environment. Additionally evidence was given by a Doctor that efforts were not made to fully investigate Lee Terence Curran’s episodes of loss of consciousness because, the Doctor explained, it was common for prisoners to claim to have suffered losses of consciousness as a form of drug seeking behaviour .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct NICE-compliant investigations of loss of consciousness
Wider context from the report “(1) The Prisons and Probation Ombudsman investigated Lee Terence Curran’s death. At the conclusion of that investigation certain recommendations were made, two of which were as follows:
a. “The Head of Healthcare should ensure that healthcare staff take full account of family history when arranging clinical investigations for prisoners who report, or are observed to have possible signs of high cholesterol or hypertension”.
b. “The Head of Healthcare should develop a protocol that is NICE compliant for investigating episodes of loss of consciousness and should ensure that staff conduct clinical investigations of prisoners who experience such episodes.”
Both of these recommendations were accepted. However the evidence given at the Inquest in relation to the implementation of recommendation a. was that all prisoners coming to Forest Bank Prison undertake the reception screening process and any prisoner with any identified, or any sign of, hypertension is referred to the hypertension clinic. A full account of the prisoner’s family history is then taken at that clinic. There was no evidence that any action had been taken to address that part of the Ombudsman’s recommendation that related to prisoners (such as Lee Terence Curran) who reported or showed signs of having high cholesterol.
Likewise with recommendation b. The evidence given at the Inquest with regard to the implementation of that recommendation was that any individual who had a loss of consciousness would be automatically referred to a Doctor. That action does not encompass the whole of the Ombudsman’s recommendation. Particularly it does not ensure that investigations of episodes of loss of consciousness are NICE compliant nor does it ensure that staff conduct clinical investigations of prisoners who experience such episodes. It should be remembered here that Doctors saw Lee Terence Curran on five occasions following episodes of loss of consciousness and the NICE guidelines were not followed at any time .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable 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 accurate and evidentially grounded entries in prisoners’ medical notes
Wider context from the report “(2) Evidence given at the Inquest revealed a potential need for the training of Prison staff as to the manner in which they make entries in prisoners’ medical notes. Expressly, incorrect, and potentially misleading, information had been entered in Lee Terence Curran’s medical notes concerning the episodes of loss of consciousness that he experienced. For example a nurse described one such episode as a “petit mal seizure,” whilst evidence at the Inquest made it clear that such could not have been the case. In addition those attending information did not make the basis upon which they were entering that information clear, that is they entered information that indicated that they had witnessed an event when they had not .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct clinical investigations of prisoners experiencing loss of consciousness
Wider context from the report “(1) The Prisons and Probation Ombudsman investigated Lee Terence Curran’s death. At the conclusion of that investigation certain recommendations were made, two of which were as follows:
a. “The Head of Healthcare should ensure that healthcare staff take full account of family history when arranging clinical investigations for prisoners who report, or are observed to have possible signs of high cholesterol or hypertension”.
b. “The Head of Healthcare should develop a protocol that is NICE compliant for investigating episodes of loss of consciousness and should ensure that staff conduct clinical investigations of prisoners who experience such episodes.”
Both of these recommendations were accepted. However the evidence given at the Inquest in relation to the implementation of recommendation a. was that all prisoners coming to Forest Bank Prison undertake the reception screening process and any prisoner with any identified, or any sign of, hypertension is referred to the hypertension clinic. A full account of the prisoner’s family history is then taken at that clinic. There was no evidence that any action had been taken to address that part of the Ombudsman’s recommendation that related to prisoners (such as Lee Terence Curran) who reported or showed signs of having high cholesterol.
Likewise with recommendation b. The evidence given at the Inquest with regard to the implementation of that recommendation was that any individual who had a loss of consciousness would be automatically referred to a Doctor. That action does not encompass the whole of the Ombudsman’s recommendation. Particularly it does not ensure that investigations of episodes of loss of consciousness are NICE compliant nor does it ensure that staff conduct clinical investigations of prisoners who experience such episodes . It should be remembered here that Doctors saw Lee Terence Curran on five occasions following episodes of loss of consciousness and the NICE guidelines were not followed at any time.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable 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 take full account of family history when clinically investigating prisoners with possible high cholesterol
Wider context from the report “(1) The Prisons and Probation Ombudsman investigated Lee Terence Curran’s death. At the conclusion of that investigation certain recommendations were made, two of which were as follows:
a. “The Head of Healthcare should ensure that healthcare staff take full account of family history when arranging clinical investigations for prisoners who report, or are observed to have possible signs of high cholesterol or hypertension”.
b. “The Head of Healthcare should develop a protocol that is NICE compliant for investigating episodes of loss of consciousness and should ensure that staff conduct clinical investigations of prisoners who experience such episodes.”
Both of these recommendations were accepted. However the evidence given at the Inquest in relation to the implementation of recommendation a. was that all prisoners coming to Forest Bank Prison undertake the reception screening process and any prisoner with any identified, or any sign of, hypertension is referred to the hypertension clinic. A full account of the prisoner’s family history is then taken at that clinic. There was no evidence that any action had been taken to address that part of the Ombudsman’s recommendation that related to prisoners (such as Lee Terence Curran) who reported or showed signs of having high cholesterol.
Likewise with recommendation b. The evidence given at the Inquest with regard to the implementation of that recommendation was that any individual who had a loss of consciousness would be automatically referred to a Doctor. That action does not encompass the whole of the Ombudsman’s recommendation. Particularly it does not ensure that investigations of episodes of loss of consciousness are NICE compliant nor does it ensure that staff conduct clinical investigations of prisoners who experience such episodes. It should be remembered here that Doctors saw Lee Terence Curran on five occasions following episodes of loss of consciousness and the NICE guidelines were not followed at any time.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 doctors’ awareness of NICE guidelines for transient loss of consciousness
Wider context from the report “(3) Evidence given at the Inquest also revealed a need for the training of Doctors working in prisons in that Doctors who provided general practice sessions at the prison (and in the community) gave evidence that they were unaware of the NICE Guidelines for Transient Loss of Consciousness Management in Adults and Young People despite such episodes being common in a prison environment . Additionally evidence was given by a Doctor that efforts were not made to fully investigate Lee Terence Curran’s episodes of loss of consciousness because, the Doctor explained, it was common for prisoners to claim to have suffered losses of consciousness as a form of drug seeking behaviour.
” Open source report
3 Feb 2014 Amy Friar · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 1 Lack of a universal emergency code across the prison estate 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
Amy Friar · 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
Amy Friar was found partially suspended by a ligature in her cell at HMP Downview on 30 March 2011 and was already dead when found. The inquest concluded that she took her own life, with hanging recorded as the cause of death. The report raised concern that differing emergency codes across prisons could cause confusion and delay assistance in other circumstances, although this did not contribute to Ms Friar’s death.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Lack of a universal emergency code across the prison estate
Wider context from the report “The prison officer who sounded the alarm had recently arrived at HMP Downview from a different prison. That prison used different emergency codes to those which were used at HM Downview. As a consequence, initially the wrong code was called and there was confusion over the nature of the incident. In this particular incident that confusion did not impact upon or contribute to Ms Friar’s death.
However, the lack of a universal emergency code across the prison estate has the potential to cause confusion and which, in different circumstances, may cause a delay in assistance being received and thereby lead to circumstances that create a risk of other deaths occurring in the future.
Evidence was heard that in January 2013 a new PSI (PSI 03/2013) established two different sets of emergency codes, one colour and one numeric. Code Blue being for the more serious breathing/collapse incidents and Code Red being for less serious blood/burns injuries. The equivalent numeric codes were One for breathing/collapse and Two for blood/burns.
In my opinion retaining two different codes does not remove the potential for confusion where prison staff move between prisons , as referred to above.
Further, I heard evidence that at HMP Downview the numeric codes are used and that a card has been developed which is of a size to fit at the rear of the prison officers identity card, meaning that it is with the prison officer at all times whilst they are at work. That card sets out in clear terms what the emergency codes are and the situations to which they apply. In addition posters have been put up in a large number of areas around the prison detailing the same information. Consideration might be given to extending this example of best practice across the whole prison estate.
” Open source report
21 Jan 2014 William Howard DOWLING and Victoria Elaine ROSE · Prevention of Future Deaths report Wiltshire and Swindon
View report summary
Concerns raised 3 Lack of arrangements enabling doctors to report relevant information during firearms licence terms View source Failure to enable General Practitioners to share public-safety information with relevant authorities View source Lack of independent and transparent firearms licensing decisions for current or former police employees 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
William Howard DOWLING and Victoria Elaine ROSE · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 2 March 2013, William Howard Dowling shot Victoria Elaine Rose twice in the head before shooting himself in the head. The report raised concerns about information sharing between general practitioners and firearms licensing authorities, the wider public-safety implications of confidentiality, and the independence and transparency of firearms licensing decisions involving current or former police employees.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Lack of arrangements enabling doctors to report relevant information during firearms licence terms
Wider context from the report “(1) During the course of the hearing I heard evidence from ███████ Wiltshire Police Firearms Licensing Manager, who indicated to me that at the present moment in time aside from a letter (copy attached marked A – since July 2011) which is sent to General Practitioners when firearms licence applications are successful or where they are renewed, giving a doctor the opportunity to relay relevant information in relation to their patient within 14 days, there is currently no memorandum of understanding or legislation that allows doctors the ability during the duration of the term of a firearms license, which stands at 5 years, to report matters which may have a bearing on that patient’s suitability to hold a firearms license and possess firearms . Doctors of course are bound at the present moment in time by patient confidentiality. I am concerned that this restriction may impede the firearms authority from making crucial decisions as regards individuals possessing firearms and continuing to hold a firearms licence in circumstances which, at present, may not come before the attention of the Firearms Authority unless the matter has ordinarily come before the police’s attention as a consequence of other aspects of their duties.
In evidence from ███████ she made me aware that Wiltshire Police through the cooperation of NHS Wiltshire Clinical Commissioning Group and two Doctor’s Surgeries were piloting a scheme (directly prompted Victoria’s two sons as a result of his tragedy) effective from September 2013, to allow an increase in the sharing of information in particular having a bearing on the suitability of an individual to hold a firearms licence. She indicated that as a result of this pilot scheme an individual’s firearms were taken away at short notice as a result of the information received from the General Practitioner. This pilot scheme seems to me to be an utterly sensible idea although at present it is a pilot scheme and is not a national concept . This ought to be urgently 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 Failure to enable General Practitioners to share public-safety information with relevant authorities
Wider context from the report “(2) I am also concerned that any review arising out of this letter should not be singularly restricted as regards sharing information solely related to the suitability of somebody to hold a firearms licence. Information sharing with a view to public safety should be a reason for General Practitioners to make relevant authority(s) aware and I have in mind here the example of a driver whose eyesight is failing and where advice given from a GP to inform the DVLA, however that driver chooses not to do so as it will mean their licence may be revoked. If it is a matter of public safety then I am concerned at present moment in time that confidentiality appears to outweigh the concept of public safety .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Lack of independent and transparent firearms licensing decisions for current or former police employees
Wider context from the report “(3) I am also concerned as regards decisions being made relating to firearms licensing in respect of current employees within that licensing organisation’s (ie the Police) employment or even former employees . Licensing and the determination of such matters should be seen to be transparent and independent . In evidence although relating to matters some 16 years previously there were issues raised by family concerning complaints by Mr Dowling’s ex wife at the time they were getting divorced that appeared to have been “brushed under the carpet” by the police in respect of which Bill was a serving officer. In any event those concerns were not dealt with satisfactorily from the complainant’s perspective. I am concerned that to have a firearms licensing authority dealing with applications from existing police employees or even former employees of that police force is open to possible abuse . Bill Dowling was an exceptionally well known and respected former police employee and my concern is that such matters relative to firearms are so serious that consideration ought to be given to introducing an independent layer so as to ensure independence and transparency .
” Open source report
16 Dec 2013 Cynthia Fretwell · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 5 Delays in consultation and responses to telephone referrals View source Inability of reception staff to interrupt GPs to alert and inform them of changes in a patient’s condition following telephone referrals View source Failure to fully and properly document discussions with patients or their families View source Failure to determine an adequate threshold for telephone versus home consultation View source Failure to fully assess patients’ mental capacity when they refuse medical treatment or hospital admission 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
Cynthia Fretwell · 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
Cynthia Fretwell, aged 84, was admitted to hospital with abdominal pain, obstructive jaundice and suspected gallbladder inflammation, but was discharged after treatment with antibiotics. She later became unwell at home, was not admitted to hospital after GP contacts including a telephone consultation, and died that evening from peritonitis resulting from an infected gall bladder that had not responded to antibiotics. Concerns included telephone referral systems and responses, the threshold for telephone versus home consultations, assessment of mental capacity when refusing treatment or admission, and documentation of discussions.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Delays in consultation and responses to telephone referrals
Wider context from the report “(1) Telephone referrals and the lack of an effective system for conveying and responding to information between the caller and the doctor. Specifically, I had concerns about the following aspects:
(a) The inability of reception staff to interrupt a GP during surgery for the purposes of alerting and informing the doctor of a change in the patient’s condition following a telephone referral.
(b) Timely consultation and timely responses to telephone referrals from patients and their families.
(c) The threshold for determining whether a telephone consultation is adequate or whether a home consultation should be undertaken.
(2) A full assessment of the patient’s mental capacity in a situation where they are refusing medical treatment or admission to hospital.
(3) Full and proper documentation of the discussions between the doctor and the patient/patient’s family in those circumstances.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Inability of reception staff to interrupt GPs to alert and inform them of changes in a patient’s condition following telephone referrals
Wider context from the report “(1) Telephone referrals and the lack of an effective system for conveying and responding to information between the caller and the doctor. Specifically, I had concerns about the following aspects:
(a) The inability of reception staff to interrupt a GP during surgery for the purposes of alerting and informing the doctor of a change in the patient’s condition following a telephone referral.
(b) Timely consultation and timely responses to telephone referrals from patients and their families.
(c) The threshold for determining whether a telephone consultation is adequate or whether a home consultation should be undertaken.
(2) A full assessment of the patient’s mental capacity in a situation where they are refusing medical treatment or admission to hospital.
(3) Full and proper documentation of the discussions between the doctor and the patient/patient’s family in those circumstances.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to fully and properly document discussions with patients or their families
Wider context from the report “(1) Telephone referrals and the lack of an effective system for conveying and responding to information between the caller and the doctor. Specifically, I had concerns about the following aspects:
(a) The inability of reception staff to interrupt a GP during surgery for the purposes of alerting and informing the doctor of a change in the patient’s condition following a telephone referral.
(b) Timely consultation and timely responses to telephone referrals from patients and their families.
(c) The threshold for determining whether a telephone consultation is adequate or whether a home consultation should be undertaken.
(2) A full assessment of the patient’s mental capacity in a situation where they are refusing medical treatment or admission to hospital.
(3) Full and proper documentation of the discussions between the doctor and the patient/patient’s family in those circumstances.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to determine an adequate threshold for telephone versus home consultation
Wider context from the report “(1) Telephone referrals and the lack of an effective system for conveying and responding to information between the caller and the doctor. Specifically, I had concerns about the following aspects:
(a) The inability of reception staff to interrupt a GP during surgery for the purposes of alerting and informing the doctor of a change in the patient’s condition following a telephone referral.
(b) Timely consultation and timely responses to telephone referrals from patients and their families.
(c) The threshold for determining whether a telephone consultation is adequate or whether a home consultation should be undertaken.
(2) A full assessment of the patient’s mental capacity in a situation where they are refusing medical treatment or admission to hospital.
(3) Full and proper documentation of the discussions between the doctor and the patient/patient’s family in those circumstances.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Ministry of Justice; that does not assign responsibility.
PFD Monitor interpretation Failure to fully assess patients’ mental capacity when they refuse medical treatment or hospital admission
Wider context from the report “(1) Telephone referrals and the lack of an effective system for conveying and responding to information between the caller and the doctor. Specifically, I had concerns about the following aspects:
(a) The inability of reception staff to interrupt a GP during surgery for the purposes of alerting and informing the doctor of a change in the patient’s condition following a telephone referral.
(b) Timely consultation and timely responses to telephone referrals from patients and their families.
(c) The threshold for determining whether a telephone consultation is adequate or whether a home consultation should be undertaken.
(2) A full assessment of the patient’s mental capacity in a situation where they are refusing medical treatment or admission to hospital.
(3) Full and proper documentation of the discussions between the doctor and the patient/patient’s family in those circumstances.
” Open source report
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations