12 Mar 2014 Andrew Ronald Hall · Prevention of Future Deaths report Teesside
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Concerns raised 12 Absence of arrangements for staff use of CCTV screens View source Failure to administer prescribed medication View source Failure by healthcare professionals to attend to system 1 entries View source Inadequate communication between the Mental Health Team and Healthcare Unit staff about condition and self-harm risk View source Inadequate observation of patients in the healthcare unit View source Inadequate communication about required observation between the Mental Health In Reach Team and mental care unit staff View source Failure to correctly document information provided by mental healthcare nursing staff to Prison Officers View source Inadequate communication within the Mental Health team about condition and self-harm risk View source Infrequent observation of CCTV screens View source Failure by mental health and general nursing staff to take account of system 1 entries View source Failure to conduct post-closure interviews in accordance with ACCT policy View source Inadequate quality of CCTV images within the healthcare unit View source See 9 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
Andrew Ronald Hall · 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
Andrew Ronald Hall, an inmate at HM Holme House Prison, died on 27 March 2009 after causing incised wounds to his neck in a healthcare unit cell. The concerns included inadequate communication and documentation about his mental health and self-harm risk, failures in medication administration and observation, and deficiencies in CCTV quality, monitoring and staff arrangements.
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 North Tees and Hartlepool NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of arrangements for staff use of CCTV screens
Wider context from the report “11. Arrangements for staff members to use the CCTV screens were absent . (Prison service & Healthcare staff)
” 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 North Tees and Hartlepool NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to administer prescribed medication
Wider context from the report “8. Medication was not administered to the deceased on 23 March 2009 and 24 March 2009 as prescribed . (Medical healthcare staff)
” 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 North Tees and Hartlepool NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure by healthcare professionals to attend to system 1 entries
Wider context from the report “5. Insufficient attention was paid by healthcare professionals to the system 1 entries .
” 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 North Tees and Hartlepool NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate communication between the Mental Health Team and Healthcare Unit staff about condition and self-harm risk
Wider context from the report “3. There was inadequate communication between members of the Mental Health Team and the Healthcare Unit staff as to the deceased’s perceived condition and level of risk of self-harm .
” 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 North Tees and Hartlepool NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate observation of patients in the healthcare unit
Wider context from the report “9. The deceased was not adequately observed between 6.30pm and 7.30pm on 27 March 2009. (Healthcare staff/Prison discipline officers)
” 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 North Tees and Hartlepool NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate communication about required observation between the Mental Health In Reach Team and mental care unit staff
Wider context from the report “4. There was inadequate communication between the Mental Health In Reach Team and the mental care unit staff as to the type and level of observation required when the deceased was re-admitted to the Healthcare Unit on 23 March 2009.
” 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 North Tees and Hartlepool NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to correctly document information provided by mental healthcare nursing staff to Prison Officers
Wider context from the report “1. In the assessment of risk and risk management the jury found (inter alia) information provided by mental healthcare nursing staff to Prison Officers was not correctly documented .
” 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 North Tees and Hartlepool NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate communication within the Mental Health team about condition and self-harm risk
Wider context from the report “2. There was inadequate communication between members of the Mental Health team as to the deceased’s condition and the level of risk of self-harm .
” 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 North Tees and Hartlepool NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Infrequent observation of CCTV screens
Wider context from the report “12. There was infrequent observation of the CCTV screens on 27 March 2009. (Prison service & Healthcare staff)
” 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 North Tees and Hartlepool NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure by mental health and general nursing staff to take account of system 1 entries
Wider context from the report “6. That both mental health staff and general nursing staff inadequately took into account the entry made by ████████
” 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 North Tees and Hartlepool NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct post-closure interviews in accordance with ACCT policy
Wider context from the report “7. That a post-closure interview in accordance with the (then) ACCT policy should have been conducted . (Prison staff, healthcare staff and Mental Health team)
” 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 North Tees and Hartlepool NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate quality of CCTV images within the healthcare unit
Wider context from the report “10. The quality of CCTV images within the healthcare unit was inadequate . ( prison service)
” 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