Concerns raised 2 Failure to specify and plan the support to be offered by staff View source Failure to open an ACCT for a person likely to be upset 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
Michelle Barnes · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Michelle Barnes was found dead in her cell at HMP Low Newton on 16 December 2015, five days after giving birth and three days after returning to prison. The report identified concerns that an ACCT was not opened after she was told her child would be taken into care, that the support to be offered was not clearly defined or documented, and that other factors probably contributed to her death according to the inquest.
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 National Offender Management Service Equality, Rights and Decency Group; that does not assign responsibility.
PFD Monitor interpretation Failure to specify and plan the support to be offered by staff
Wider context from the report “After the prisoner made a decision to prevent Michelle from further visiting her child in hospital, two officers who did not know Michelle and who Michelle did not know particularly well, were tasked to tell Michelle the news and to further confirm her child was to be taken into care. The senior of those officers, chose not to open an ACCT, notwithstanding she described Michelle as being very upset and crying but instead made an entry in the wing observation book that staff were to “offer support”. It should have been clear to all that Michelle was likely to be upset upon receiving such news. Nothing was documented to indicate or to explain what “support” could or should be offered by staff. There was no clear plan as to what the officer meant by the entry or to what should be delivered. Is there some means of offering support short of an ACCT, was an issue raised by the evidence.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Offender Management Service Equality, Rights and Decency Group; that does not assign responsibility.
PFD Monitor interpretation Failure to open an ACCT for a person likely to be upset
Wider context from the report “After the prisoner made a decision to prevent Michelle from further visiting her child in hospital, two officers who did not know Michelle and who Michelle did not know particularly well, were tasked to tell Michelle the news and to further confirm her child was to be taken into care. The senior of those officers, chose not to open an ACCT, notwithstanding she described Michelle as being very upset and crying but instead made an entry in the wing observation book that staff were to “offer support”. It should have been clear to all that Michelle was likely to be upset upon receiving such news . Nothing was documented to indicate or to explain what “support” could or should be offered by staff. There was no clear plan as to what the officer meant by the entry or to what should be delivered. Is there some means of offering support short of an ACCT, was an issue raised by the evidence.
” Open source report
Concerns raised 11 Serious drug problem in the prison View source Failure of healthcare and discipline staff to know the overdose policy and prescribed response View source Complacency about prisoners presenting under the influence of drugs View source Failure to request emergency attendance by the on-duty nurse View source Failure of healthcare and discipline staff to provide an integrated response to drug-related presentations View source Failure to prepare an ongoing treatment plan for prisoners receiving nursing care View source Lack of formal training and detailed understanding of the current overdose policy View source Inadequate recording of nursing care and required actions View source Lack of operational guidance for responding to suspected overdoses View source Complacency and acceptance by staff of the prison drug problem View source Delays and uncertainty in calling an emergency ambulance and using the code blue call View source See 8 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Kevin Anthony Forster · 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
Kevin Anthony Forster died in his prison cell at HMP Durham on 14 September 2014 after taking drugs he had hidden within his body. Staff identified that he was under the influence of an unknown substance, but no thorough or clinical assessment was undertaken. The principal concerns included inadequate policies, training, assessment, observation, treatment planning, communication and emergency response to prisoners who may have overdosed.
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 National Offender Management Service Equality, Rights and Decency Group; that does not assign responsibility.
PFD Monitor interpretation Serious drug problem in the prison
Wider context from the report “1. It was clear from evidence that there is a serious drug problem in HMP Durham . This has led to a degree of complacency and acceptance by staff of that situation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Offender Management Service Equality, Rights and Decency Group; that does not assign responsibility.
PFD Monitor interpretation Failure of healthcare and discipline staff to know the overdose policy and prescribed response
Wider context from the report “2. Healthcare staff were unaware of what, if any, drugs policy was in place at the time . A policy known as a “Drugs Overdose Policy” which had, in various guises been in operation since 2008 included a definition of overdose as the “purposeful or accidental act of ingesting an amount of a drug or substance that may cause harm to health”. As such, the ingestion of unknown drugs is de facto harmful to health and would constitute an overdose which should lead to the triggering of the Overdose Policy. Both discipline and healthcare staff were unaware of the policy, the “overdose” definition and the prescribed steps which should then ensue .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Offender Management Service Equality, Rights and Decency Group; that does not assign responsibility.
PFD Monitor interpretation Complacency about prisoners presenting under the influence of drugs
Wider context from the report “9. As mentioned earlier the evidence indicated that there was a degree of complacency about prisoners presenting under the influence of drugs and the risks associated therewith (at handover one officer said to another “there are some prisoners sleeping it off”). Due to the scale of the issue, the potential risk to health of prisoners is such that there needs to be absolute clarity of response and care for prisoners who so present. The evidence indicated that a more integrated approach between healthcare staff and discipline staff would be beneficial notwithstanding there were good lines of communication between the two.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Offender Management Service Equality, Rights and Decency Group; that does not assign responsibility.
PFD Monitor interpretation Failure to request emergency attendance by the on-duty nurse
Wider context from the report “7. Discipline staff summoned healthcare staff and perhaps not appreciating the significance of the apparent health of the deceased, did not call for the on-duty nurse to attend as an emergency, but just asked for the nurse to attend . Such an oversight could lead to a delay which in certain circumstances might be very significant.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Offender Management Service Equality, Rights and Decency Group; that does not assign responsibility.
PFD Monitor interpretation Failure of healthcare and discipline staff to provide an integrated response to drug-related presentations
Wider context from the report “9. As mentioned earlier the evidence indicated that there was a degree of complacency about prisoners presenting under the influence of drugs and the risks associated therewith (at handover one officer said to another “there are some prisoners sleeping it off”). Due to the scale of the issue, the potential risk to health of prisoners is such that there needs to be absolute clarity of response and care for prisoners who so present. The evidence indicated that a more integrated approach between healthcare staff and discipline staff would be beneficial notwithstanding there were good lines of communication between the two.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Offender Management Service Equality, Rights and Decency Group; that does not assign responsibility.
PFD Monitor interpretation Failure to prepare an ongoing treatment plan for prisoners receiving nursing care
Wider context from the report “6. There was a lack of an on-going treatment plan prepared for the deceased by nursing staff who attended on him and there was inadequate recording that they had done and what they had to do.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Offender Management Service Equality, Rights and Decency Group; that does not assign responsibility.
PFD Monitor interpretation Lack of formal training and detailed understanding of the current overdose policy
Wider context from the report “3. Upon obtaining the contract for healthcare at HMP Durham, G4S have instituted have implemented a new policy, but evidence was given that staff had not been given any formal training on it , though the document (running to 12 pages) had been emailed. Evidence indicated that there was still a lack of appreciation of the detail of the policy now in force .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Offender Management Service Equality, Rights and Decency Group; that does not assign responsibility.
PFD Monitor interpretation Inadequate recording of nursing care and required actions
Wider context from the report “6. There was a lack of an on-going treatment plan prepared for the deceased by nursing staff who attended on him and there was inadequate recording that they had done and what they had to do .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Offender Management Service Equality, Rights and Decency Group; that does not assign responsibility.
PFD Monitor interpretation Lack of operational guidance for responding to suspected overdoses
Wider context from the report “4. The evidence indicated that there was a lack of guidance as to how staff should react when faced with a person who had overdosed ; no local procedures as envisaged by the policy were disclosed , what should be done where there is no indicator as to what substance had been ingested and what would be the appropriate level of observations recognising that (Policy paragraph 8.1) symptoms may develop later .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Offender Management Service Equality, Rights and Decency Group; that does not assign responsibility.
PFD Monitor interpretation Complacency and acceptance by staff of the prison drug problem
Wider context from the report “1. It was clear from evidence that there is a serious drug problem in HMP Durham. This has led to a degree of complacency and acceptance by staff of that situation .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Offender Management Service Equality, Rights and Decency Group; that does not assign responsibility.
PFD Monitor interpretation Delays and uncertainty in calling an emergency ambulance and using the code blue call
Wider context from the report “8. The evidence indicated that there was a delay (albeit a short one) in either healthcare or discipline staff calling for an emergency ambulance to attend and/or whether code blue as an expression was used . Other inquests have clearly identified issues at the establishment about the calling of an emergency ambulance.
” Open source report
Concerns raised 4 Failure to give sufficient weight to mental health staff opinions in ACCT reviews View source Failure of ACCT review members to read the ACCT document before reviews View source Failure to ensure mental health staff attend relevant ACCT reviews View source Failure to share mental health information with other ACCT review members 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
Geraldine Liege Kilborn · 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
Geraldine Liege Kilborn died in HMP Low Newton after repeatedly self-harming over the 22 days following her reception into the prison; the Jury could not determine her intention when she hung herself. The principal concerns were inadequate sharing and weighting of mental-health information during ACCT reviews, limited review of ACCT records by some panel members, and questions about review-panel membership and her location at the time of 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 National Offender Management Service Equality, Rights and Decency Group; that does not assign responsibility.
PFD Monitor interpretation Failure to give sufficient weight to mental health staff opinions in ACCT reviews
Wider context from the report “(1) There was a clear breakdown in sharing of information known to the mental health team with other members of some ACCT reviews. Evidence was given that there has been a change in service provision contracts since the death of the deceased and that mental health staff will now work weekends. Nevertheless, it is vital that in appropriate cases where a prisoner is on an ACCT and has had substantial mental health input that they both attend relevant ACCT reviews and their opinions are given sufficient weight . It is noted that mental health nurses never chair such ACCT reviews as case manager and in this case has revealed that even in attendance, their views might not be given sufficient weight .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Offender Management Service Equality, Rights and Decency Group; that does not assign responsibility.
PFD Monitor interpretation Failure of ACCT review members to read the ACCT document before reviews
Wider context from the report “(2) Witnesses confirmed that they often did not read much of the ACCT document prior to the ACCT review and relied more upon input of other attendees who might know the prisoner and opined their face to face assessment of the prisoner at the time. In this case, some ACCT review members had limited day to day experience of the deceased, whose temperament and presentation could change “like a light switch” and therefore face to face presentation could well be misleading. Thus in cases where the ACCT review was dealing with a particularly complex challenging prisoner and where an enhanced review was called for, it would seem appropriate for further consideration to be given to the question of review panel membership generally as well as, as above, mental health input in particular.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Offender Management Service Equality, Rights and Decency Group; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure mental health staff attend relevant ACCT reviews
Wider context from the report “(1) There was a clear breakdown in sharing of information known to the mental health team with other members of some ACCT reviews. Evidence was given that there has been a change in service provision contracts since the death of the deceased and that mental health staff will now work weekends. Nevertheless, it is vital that in appropriate cases where a prisoner is on an ACCT and has had substantial mental health input that they both attend relevant ACCT reviews and their opinions are given sufficient weight. It is noted that mental health nurses never chair such ACCT reviews as case manager and in this case has revealed that even in attendance, their views might not be given sufficient weight.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Offender Management Service Equality, Rights and Decency Group; that does not assign responsibility.
PFD Monitor interpretation Failure to share mental health information with other ACCT review members
Wider context from the report “(1) There was a clear breakdown in sharing of information known to the mental health team with other members of some ACCT reviews. Evidence was given that there has been a change in service provision contracts since the death of the deceased and that mental health staff will now work weekends. Nevertheless, it is vital that in appropriate cases where a prisoner is on an ACCT and has had substantial mental health input that they both attend relevant ACCT reviews and their opinions are given sufficient weight. It is noted that mental health nurses never chair such ACCT reviews as case manager and in this case has revealed that even in attendance, their views might not be given sufficient weight.
” Open source report
Concerns raised 4 Failure to visit the prisoner’s cell during a roll check View source Failure to identify domestic abuse risk factors during prison reception and risk assessment View source Restricted observation of the toilet area from the cell observation window View source Lack of refresher training in basic life support 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
Damion Anthony Andre Martin · 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
Damion Anthony Andre Martin was remanded to HMP Liverpool on 6 December 2011 and was found hanging in the toilet area of his cell on 11 December 2011; attempts to resuscitate him were unsuccessful. The report raised concerns about the identification of domestic-abuse-related suicide risk during reception, basic life-support refresher training, the restricted view into the toilet area, and whether a prison officer completed a roll-check visit.
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 National Offender Management Service Equality, Rights and Decency Group; that does not assign responsibility.
PFD Monitor interpretation Failure to visit the prisoner’s cell during a roll check
Wider context from the report “Notwithstanding documentation to the contrary, a prison officer upon his roll check at approximately 5.15am did not visit Mr Martin’s cell .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Offender Management Service Equality, Rights and Decency Group; that does not assign responsibility.
PFD Monitor interpretation Failure to identify domestic abuse risk factors during prison reception and risk assessment
Wider context from the report “During the initial prison reception and risk assessment, the domestic nature of Mr Martin’s alleged charges of Common Assault and Witness Intimidation against his girl friend were not identified , notwithstanding it was considered to be a known suicidal risk factor.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Offender Management Service Equality, Rights and Decency Group; that does not assign responsibility.
PFD Monitor interpretation Restricted observation of the toilet area from the cell observation window
Wider context from the report “The observation window to the w.c. area of cell 5 had a restricted view which did not extend to the area of the w.c. Mr Martin was found hanging.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Offender Management Service Equality, Rights and Decency Group; that does not assign responsibility.
PFD Monitor interpretation Lack of refresher training in basic life support
Wider context from the report “The first prison officer to respond to Mr Martin did not commence CPR sine he felt out of date with his first aid. This raised concerns that there is no refresher training or a cycle of refresher training in basic life support .
” Open source report
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Addressed to National Offender Management Service Offender Safety, Rights and Responsibilities Group, now represented here by National Offender Management Service Equality, Rights and Decency Group.
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations