Concerns raised 6 Failure to make detailed notes in detainees’ custody medical records View source Lack of verbal consultation between medical practitioners and custody sergeants about detainee concerns and observation levels View source Insufficient targeted training on drug and alcohol-related risks in custody View source Insufficient training emphasis on correct observation levels View source Lack of joint training exercises for medical practitioners, custody sergeants, custody detention officers and assistants View source Failure to specify detainee observation levels precisely 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.
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AI-generated summary
Name not published · 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
The deceased was arrested on 2 October 2011 and held in custody, where he received prescribed methadone and medication for alcohol withdrawal. He was found unresponsive in his cell shortly before 9.00pm on 3 October 2011; the recorded medical cause of death was methadone intoxication, with alcohol withdrawal in a chronic alcoholic also identified. Concerns included communication between medical practitioners and custody staff, inconsistent observation levels, joint training, and training on drug and alcohol-related risks.
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 Nestor Primecare Services Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to make detailed notes in detainees’ custody medical records
Wider context from the report “1. That consideration be given to issuing guidance that whenever a detainee is attended upon by a medical practitioner there should be a verbal consultation between the medical practitioner and custody sergeant as to any issues of concern and the level of observations to be had for that detainee in addition to the medical practitioner making detailed notes on the detainee’s custody medical 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 Nestor Primecare Services Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of verbal consultation between medical practitioners and custody sergeants about detainee concerns and observation levels
Wider context from the report “1. That consideration be given to issuing guidance that whenever a detainee is attended upon by a medical practitioner there should be a verbal consultation between the medical practitioner and custody sergeant as to any issues of concern and the level of observations to be had for that detainee in addition to the medical practitioner making detailed notes on the detainee’s custody medical 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 Nestor Primecare Services Limited; that does not assign responsibility.
PFD Monitor interpretation Insufficient targeted training on drug and alcohol-related risks in custody
Wider context from the report “5. That training should include targeted training on the risks and dangers of drug and alcohol abuse, including methadone intoxication and alcohol withdrawal , particularly if the detainee is likely to be in custody for upwards of 24 hours.
” 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 Nestor Primecare Services Limited; that does not assign responsibility.
PFD Monitor interpretation Insufficient training emphasis on correct observation levels
Wider context from the report “3. That training should provide targeted emphasis on the correct levels of observation .
” 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 Nestor Primecare Services Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of joint training exercises for medical practitioners, custody sergeants, custody detention officers and assistants
Wider context from the report “2. That consideration be given to the provision of joint training exercises for medical practitioners, custody sergeants and custody detention officers and assistants .
” 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 Nestor Primecare Services Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to specify detainee observation levels precisely
Wider context from the report “4. That consideration should be given to eliminating the phrase ‘continue observations at the current level’ and require that doctors and custody sergeants specify the level of observation precisely .
” Open source report
18 Sep 2014 Brian Christopher Dalrymple · Prevention of Future Deaths report West London
View report summary
Concerns raised 6 Absence of a comprehensive and accessible computerised clinical record for each detainee View source Employment of medical practitioners without knowledge necessary to their role View source Inadequate routine medical assessment of segregated detainees View source Lack of detention staff awareness and recognition of mental-health indicators View source Failure to actively communicate relevant observations to healthcare staff View source Failure to bring potential mental-health indicators to responsible healthcare 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.
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AI-generated summary
Brian Christopher Dalrymple · 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
Brian Christopher Dalrymple died at Colnbrook Immigration Removal Centre on 31 July 2011 after a fatal rupture associated with extreme hypertension, which he declined to have treated and monitored for most of his detention. The report raised concerns that indicators of his deteriorating mental health were not recognised or communicated to healthcare staff, that medical practitioners lacked necessary knowledge, that medical visits to segregated detainees were inadequate, and that clinical records were not comprehensive or accessible.
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 Nestor Primecare Services Limited; that does not assign responsibility.
PFD Monitor interpretation Absence of a comprehensive and accessible computerised clinical record for each detainee
Wider context from the report “(5)
The absence of a comprehensive and accessible (computerised) clinical record relating to each detainee at IRCs Harmondsworth and Colnbrook.
” 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 Nestor Primecare Services Limited; that does not assign responsibility.
PFD Monitor interpretation Employment of medical practitioners without knowledge necessary to their role
Wider context from the report “(3)
Medical practitioners may be employed at Harmondsworth IRC without knowledge necessary to that role.
The locum GP who gave evidence at the inquest was unaware of Detention Centre Rules 2001 or of the duties imposed on him- rule 35, for example. He was also unaware that healthcare staff had access to wing history documents.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nestor Primecare Services Limited; that does not assign responsibility.
PFD Monitor interpretation Inadequate routine medical assessment of segregated detainees
Wider context from the report “(4)
Routine medical visits to segregated detainees are inadequate properly to assess detainees' healthcare needs.
The evidence was that each detainee would be asked through the wicket “Any medical problems?”, and if the answer was negative, there would be no further interaction- witness ████████ described the practice as “not fit for purpose” ;
” 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 Nestor Primecare Services Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of detention staff awareness and recognition of mental-health indicators
Wider context from the report “(1)
There is a lack of awareness amongst detention staff at Harmondsworth of: (i) behaviours (and reported experiences) which may indicate the existence of mental health issues affecting particular detainees- particularly in relation to schizophrenia ; and (ii) the need to ensure that such potential indicators are brought to the attention of those responsible for the particular detainee's healthcare.
Despite the training which had been received by such staff prior to Mr Dalrymple's detention, indications of his mental ill-health were not recognised as such. Witness ████████ identified events and circumstances from the point of Mr Dalrymple's presentation at port and throughout his period of detention that he said “should have been picked up” and triggered a psychiatric assessment (for which there was an “overwhelming need”). In Mr Dalrymple's case such concerns were not properly acknowledged at Harmondsworth.
The DCOs had not received sufficient training in the recognition of relevant indicators. The evidence was that officers were and remain unclear whether particular behaviours, unusual in local society at large, should be regarded as significant amongst the population at Harmondsworth.
It was clear from the evidence given by the Deputy Immigration Manager, and that of a clinical Contract Manager / Interim Healthcare Manager that significant reliance is placed on the detention officers to raise concerns over a detainee's mental heath.
” 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 Nestor Primecare Services Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to actively communicate relevant observations to healthcare staff
Wider context from the report “(2)
Relevant and significant observations recorded by detention centre staff and others are not actively brought to the attention of relevant healthcare staff.
In the present case, custody officers' entries in wing history records were sufficient (alone or in combination) to alert a reader to the possibility of mental health issues affecting Mr Dalrymple whilst detained at Harmondsworth IRC; these indicators were missed. In the terms of Witness ████████ the overall picture of developing (relapsing) mental disorder was not available to any one set of people.
” 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 Nestor Primecare Services Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to bring potential mental-health indicators to responsible healthcare staff
Wider context from the report “(1)
There is a lack of awareness amongst detention staff at Harmondsworth of: (i) behaviours (and reported experiences) which may indicate the existence of mental health issues affecting particular detainees- particularly in relation to schizophrenia; and (ii) the need to ensure that such potential indicators are brought to the attention of those responsible for the particular detainee's healthcare.
Despite the training which had been received by such staff prior to Mr Dalrymple's detention, indications of his mental ill-health were not recognised as such. Witness ████████ identified events and circumstances from the point of Mr Dalrymple's presentation at port and throughout his period of detention that he said “should have been picked up” and triggered a psychiatric assessment (for which there was an “overwhelming need”). In Mr Dalrymple's case such concerns were not properly acknowledged at Harmondsworth.
The DCOs had not received sufficient training in the recognition of relevant indicators. The evidence was that officers were and remain unclear whether particular behaviours, unusual in local society at large, should be regarded as significant amongst the population at Harmondsworth.
It was clear from the evidence given by the Deputy Immigration Manager, and that of a clinical Contract Manager / Interim Healthcare Manager that significant reliance is placed on the detention officers to raise concerns over a detainee's mental heath.
” Open source report
1 Aug 2013 Annie Rose GIBSON · Prevention of Future Deaths report West Yorkshire (East)
View report summary
Concerns raised 1 Failure of training protocols and Care Plans to ensure emergency-service calls and ambulance attendance despite client wishes 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.
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AI-generated summary
Annie Rose GIBSON · 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
Annie Rose Gibson, an 84-year-old woman living alone, was found unresponsive at home after a fall the previous day and was pronounced dead on 13 October 2012. The post-mortem cause of death was recorded as hypothermia, immobility, and fractured pelvis with haemorrhage. The principal concern was that emergency medical assistance was not obtained despite the fall and injury, and that hospital treatment might have prevented the development of hypothermia and the 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 Nestor Primecare Services Limited; that does not assign responsibility.
PFD Monitor interpretation Failure of training protocols and Care Plans to ensure emergency-service calls and ambulance attendance despite client wishes
Wider context from the report “My recommendations are that you should address situations such as this in your training protocols and Care Plans to ensure that your carers would always, notwithstanding the wishes of your client, call the Emergency Services and ensure ambulance attendance . I also recommend that the wishes of the client would have to be overridden in such a situation, in particular when relatives cannot be contacted .
” 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