Concerns raised 3 Failure to use objective and consistent criteria for risk assessment View source Lack of a plan to address the known risk-assessment problem View source Failure to ensure that recorded risk grades have a clear shared meaning 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 JAMES FITZPATRICK · 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 James Fitzpatrick had a long history of mental health problems and attended local A&E departments on three occasions in the year before his death, with two attendances followed by custody. The report identified inconsistent and inaccurate assessment of risk by healthcare professionals, with unclear risk grades recorded in the electronic custody record and no plan to address the problem despite it being known.
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 Mitie Care And Custody Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to use objective and consistent criteria for risk assessment
Wider context from the report “(1) During the course of the evidence, it became apparent that the HCPs were not using objective and/or consistent criteria to assess the risk of ████████ , meaning that (a) the grade of risk assigned to AF was inconsistent and/or inaccurate and (b) no one else knew what was meant by the grade of risk recorded in the electronic custody record.
(2) Further, none of the HPCs who gave evidence used the criteria described in the online training materials .
(3) Despite being aware of this problem, there was no plan in place to address it.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mitie Care And Custody Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of a plan to address the known risk-assessment problem
Wider context from the report “(1) During the course of the evidence, it became apparent that the HCPs were not using objective and/or consistent criteria to assess the risk of ████████, meaning that (a) the grade of risk assigned to AF was inconsistent and/or inaccurate and (b) no one else knew what was meant by the grade of risk recorded in the electronic custody record.
(2) Further, none of the HPCs who gave evidence used the criteria described in the online training materials.
(3) Despite being aware of this problem, there was no plan in place to address it .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mitie Care And Custody Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure that recorded risk grades have a clear shared meaning
Wider context from the report “(1) During the course of the evidence, it became apparent that the HCPs were not using objective and/or consistent criteria to assess the risk of ████████, meaning that (a) the grade of risk assigned to AF was inconsistent and/or inaccurate and (b) no one else knew what was meant by the grade of risk recorded in the electronic custody record .
(2) Further, none of the HPCs who gave evidence used the criteria described in the online training materials.
(3) Despite being aware of this problem, there was no plan in place to address it.
” Open source report
28 Aug 2019 Amir Siman-Tov · Prevention of Future Deaths report London (West)
View report summary
Concerns raised 14 Failure to communicate and establish vomiting during return to the healthcare unit View source Failure to provide detailed written clinical information and directions on discharge View source Failure to use the code blue procedure to summon an immediate emergency ambulance View source Failure to administer naloxone in suspected opiate overdose View source Lack of authority to require healthcare staff participation in the ACDT process View source Failure of the Consultant Forensic Psychiatrist to read ACDT documents View source Failure to apply renal impairment information in codeine overdose assessment View source Failure of healthcare staff to understand and participate in the ACDT process View source Failure to position an unresponsive patient on the floor for effective resuscitation View source Failure of hospital clinicians to account for available medical monitoring and supervision when returning patients to Colnbrook IRC View source Unclear healthcare staff roles in the ACDT process View source Failure to provide explicit clinical direction and handover to night staff View source Inconsistent checks that detainees swallow issued medication View source Failure to wake, assess and take vital signs of a sleeping patient at risk View source See 11 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
Amir Siman-Tov · 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
Amir Siman-Tov died at Colnbrook Immigration Removal Centre on 17 February 2016 after taking an overdose of codeine. The concerns included inconsistent involvement of healthcare staff in the ACDT self-harm reduction process, inconsistent medication checks, inadequate hospital discharge information and handover, insufficient monitoring after his return, and shortcomings in the emergency response.
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 Mitie Care And Custody Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate and establish vomiting during return to the healthcare unit
Wider context from the report “9. During the journey back to the Colnbrook IRC Mr Siman-Tov vomited several times. He vomited on his return to the healthcare unit. The nurse on duty was not told by the escorting custody staff and did not ask about any vomiting in the returning minus. In oral evidence the nurse said that had he known of the vomiting then he would have returned Mr Siman-Tov to the hospital for further assessment. He did not know because he did not ask and was not told .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mitie Care And Custody Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to provide detailed written clinical information and directions on discharge
Wider context from the report “8. On discharge Mr Siman-Tov in the early evening of the 16ᵗʰ February 2016 was returned to Colnbrook IRC with no accompanying clinical information at all and no advice or directions to the clinical staff at the Colnbrook IRC from the hospital . The only information provided was that one of the hospital doctors had spoken to one of the Colnbrook IRC on the telephone and that Mr Siman-Tov was “good to go”. Failure to provide detailed written information puts patients at risk .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mitie Care And Custody Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to use the code blue procedure to summon an immediate emergency ambulance
Wider context from the report “12. At approximately 3.10 on the 17ᵗʰ February 2016 Mr Siman-Tov was found to be unresponsive by custody officers. Medical assistance was called for but the required “code blue” for summoning an immediate emergency ambulance was not used .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mitie Care And Custody Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to administer naloxone in suspected opiate overdose
Wider context from the report “14. An emergency bag was brought containing adrenaline autoinjector and also naloxone which Dr Harris said was a temporary antidote to opiates . A nurse gave an injection of adrenaline into the thigh “because he thought it might help”. Naloxone was not given , even though ████████ had required emergency admission the day prior because of an opiate overdose. This puts detainees at risk .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mitie Care And Custody Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of authority to require healthcare staff participation in the ACDT process
Wider context from the report “4. The Centre Manager gave evidence that he recognised the importance of the ACDT process in keeping detainee’s safe and he actively encouraged as wide participation in the process as possible. He stated that he was only able to direct the custody staff and it was not in his power to direct that healthcare staff participated .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mitie Care And Custody Limited; that does not assign responsibility.
PFD Monitor interpretation Failure of the Consultant Forensic Psychiatrist to read ACDT documents
Wider context from the report “3. The Consultant Forensic Psychiatrist did not read the ACDT documents . This puts detainees at risk.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mitie Care And Custody Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to apply renal impairment information in codeine overdose assessment
Wider context from the report “6. Mr Siman-Tov was taken to the Hillingdon Hospital in the late morning following his overdose on the 16ᵗʰ February 2016. At the Hillingdon Hospital an assessment, examination and blood tests were taken. The blood tests indicated renal impairment. An information system TOXBASE is used in emergency departments to provide assistance to clinicians. Toxbase indicates that in renal impairment greater care must be taken in cases of codeine overdose. This was missed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mitie Care And Custody Limited; that does not assign responsibility.
PFD Monitor interpretation Failure of healthcare staff to understand and participate in the ACDT process
Wider context from the report “1. A GP who had seen Mr Siman-Tov during his stay at Colnbrook IRC told the jury that he never seen and was not aware of the content of ACDT documents and regarded the documents as a custody officer process. He told the Court that it was not customary for healthcare staff to attend or participate in the ACDT process . This puts detainees at risk.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mitie Care And Custody Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to position an unresponsive patient on the floor for effective resuscitation
Wider context from the report “13. Nursing and other staff arrived. A custody officer asked the nurse if Mr Siman-Tov should be moved to the floor for resuscitation. The nurse replied no. Dr Harris, an expert in Emergency Medicine said that he should have been moved to the floor for effective resuscitation . This puts detainees at risk .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mitie Care And Custody Limited; that does not assign responsibility.
PFD Monitor interpretation Failure of hospital clinicians to account for available medical monitoring and supervision when returning patients to Colnbrook IRC
Wider context from the report “7. The hospital clinicians gave evidence which suggested that they were not fully aware of the level of medical monitoring and supervision available at Colnbrook IRC . Mr Siman-Tov had taken an overdose whilst supervised within that facility and a decision was made to return him to that environment.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mitie Care And Custody Limited; that does not assign responsibility.
PFD Monitor interpretation Unclear healthcare staff roles in the ACDT process
Wider context from the report “2. The nurses who gave evidence similarly were uncertain of their role with respect to the ACDT process and had variable accounts of their involvement in the ACDT process . This puts detainees at risk.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mitie Care And Custody Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to provide explicit clinical direction and handover to night staff
Wider context from the report “10. Mr Siman-Tov’s care was then handed over to night staff. No explicit direction or handover was given . The explanation for this was that the observations should be second signature and did not need elaboration.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mitie Care And Custody Limited; that does not assign responsibility.
PFD Monitor interpretation Inconsistent checks that detainees swallow issued medication
Wider context from the report “5. Mr Siman-Tov expressed that he might save his medication and take as an overdose. There was conflicting evidence as to the rigour of the checks to ensure detainees had swallowed issued medicine at the time of dispensing and the nurses who gave evidence described different practices of observation . Mr Siman-Tov was able to collect sufficient codeine ultimately to be able to end his life. This lack of consistency of checks puts detainee’s at risk .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mitie Care And Custody Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to wake, assess and take vital signs of a sleeping patient at risk
Wider context from the report “11. The night nurse on duty at around 2100 noted that Mr Siman-Tov was sleeping and snoring. He made no attempt to wake him, check him or take his vital signs . This put Mr Siman-Tov at risk .
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations