17 Dec 2014 Connor Steven Paul SMITH · Prevention of Future Deaths report Liverpool
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Concerns raised 1 Failure of investigations to verify the accuracy of relevant attendance records View source
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
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.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Offender Management Service; 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
14 Aug 2013 JORDAN ANTHONY BUCKTON · Prevention of Future Deaths report Dorset
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Concerns raised 5 Insufficient mental health practitioner staffing capacity View source Failure to ensure continuity of the Emotional Wellbeing course View source Failure to complete PHQ9 assessments after antidepressant prescribing View source Failure to share relevant verbal and written risk information with prison staff View source Failure to provide timely follow-up after antidepressant prescribing View source See 2 more concerns
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
JORDAN ANTHONY BUCKTON · 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
JORDAN ANTHONY BUCKTON, aged 20, was found hanging by a ligature in his cell at HMYOI Portland on 28 January 2012. Concerns included failures to share information about his previous self-harm, to follow up after antidepressant medication was prescribed, and to continue an Emotional Wellbeing course after staff absence.
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; that does not assign responsibility.
PFD Monitor interpretation Insufficient mental health practitioner staffing capacity
Wider context from the report “(3) The failure to continue the “Emotional Wellbeing” Course in January 2012
Mr Buckton had 4 sessions with HCA Board on this course which she regarded as successful in improving his outlook on life. However she was injured on the 1st January 2012 and off work but no other mental health staff were available to continue the course. Only 2 full time members of staff were in place to carry out the work of 5 full time mental health practitioners with 1 or occasionally 2 locum nurses employed to make up the deficiency .
Whilst the jury did not regard the failure to continue the course as causative or contributory to Mr Buckton’s death they clearly felt it was important to record that the failure to continue possibly had a detrimental affect upon Mr Buckton’s wellbeing. He had been diagnosed with a personality disorder. Evidence was given that the only effective treatment for such a disorder is by talking therapy and management strategies. Greater regard should have been given to the cessation of this course and the effect upon all prisoners involved.
” Open source report × Source evidence
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; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure continuity of the Emotional Wellbeing course
Wider context from the report “(3) The failure to continue the “Emotional Wellbeing” Course in January 2012
Mr Buckton had 4 sessions with HCA Board on this course which she regarded as successful in improving his outlook on life. However she was injured on the 1st January 2012 and off work but no other mental health staff were available to continue the course . Only 2 full time members of staff were in place to carry out the work of 5 full time mental health practitioners with 1 or occasionally 2 locum nurses employed to make up the deficiency.
Whilst the jury did not regard the failure to continue the course as causative or contributory to Mr Buckton’s death they clearly felt it was important to record that the failure to continue possibly had a detrimental affect upon Mr Buckton’s wellbeing . He had been diagnosed with a personality disorder. Evidence was given that the only effective treatment for such a disorder is by talking therapy and management strategies. Greater regard should have been given to the cessation of this course and the effect upon all prisoners involved.
” Open source report × Source evidence
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; that does not assign responsibility.
PFD Monitor interpretation Failure to complete PHQ9 assessments after antidepressant prescribing
Wider context from the report “(2) Follow Up After Issue of Anti-Depressant Medication
On the 6th December 2011 one of the attending GP’s ████████ prescribed Fluoxetine to Mr Buckton on the recommendation of Healthcare Assistant Board who stated that she had discussed such prescription with the Mental Health Team and felt that Mr Buckton was depressed. ████████ did not see Mr Buckton nor did she see him after that date to check the effectiveness of the medication. The jury found there was a failure by Healthcare staff to follow up Mr Buckton’s appointment with the GP and a failure to complete a PHQ9 Assessment .
If there had been a follow up appointment with Mr Buckton at the end of January 2012 it may be that raised risk of suicide would have been spotted and treated.
The expert witness ████████ was critical of this failure. He gave evidence that a follow up appointment is recommended in the Quality and Outcomes Framework Guidance to GP’s but is also a requirement of the National Institute of Clinical Excellence Guideline 90 which recommends “For people stated on anti-depressants who are not considered to be at increased risk of suicide, normally see them after 2 weeks. See them regularly thereafter for example at intervals of 2-4 weeks in the first 3 months and then at longer intervals if the response is good. Early cessation of treatment is associated with a greater risk of relapse”.
” Open source report × Source evidence
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; that does not assign responsibility.
PFD Monitor interpretation Failure to share relevant verbal and written risk information with prison staff
Wider context from the report “(1) Information Sharing
Mr Buckton had previously hung himself in his cell at Exeter Prison on 14th February 2011 but was saved by prison staff and hospital treatment. He had also committed 3 acts of self-harm within that prison.
At the Inquest none of the wing staff at Portland were aware of his history of such acts nor had they read the C-NOMIS Record of the Potential Identified Risks form.
Evidence was given by medical witnesses that a history of previous self-harm is one of the most significant indicators of a future risk of suicide. This is also recorded in PSO 2700 and in the Self-harm Guidance issued by NOMS.
The jury reported that there was a failure to share verbal and written information within the prison in a suitable manner that all the staff members were informed so as to be able to carry out informed actions.
” Open source report × Source evidence
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; that does not assign responsibility.
PFD Monitor interpretation Failure to provide timely follow-up after antidepressant prescribing
Wider context from the report “(2) Follow Up After Issue of Anti-Depressant Medication
On the 6th December 2011 one of the attending GP’s ████████ prescribed Fluoxetine to Mr Buckton on the recommendation of Healthcare Assistant Board who stated that she had discussed such prescription with the Mental Health Team and felt that Mr Buckton was depressed. ████████ did not see Mr Buckton nor did she see him after that date to check the effectiveness of the medication. The jury found there was a failure by Healthcare staff to follow up Mr Buckton’s appointment with the GP and a failure to complete a PHQ9 Assessment.
If there had been a follow up appointment with Mr Buckton at the end of January 2012 it may be that raised risk of suicide would have been spotted and treated.
The expert witness ████████ was critical of this failure. He gave evidence that a follow up appointment is recommended in the Quality and Outcomes Framework Guidance to GP’s but is also a requirement of the National Institute of Clinical Excellence Guideline 90 which recommends “For people stated on anti-depressants who are not considered to be at increased risk of suicide, normally see them after 2 weeks. See them regularly thereafter for example at intervals of 2-4 weeks in the first 3 months and then at longer intervals if the response is good. Early cessation of treatment is associated with a greater risk of relapse”.
” 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