Recipient

Norwich Prison

First report 2 Feb 2015•Latest report 1 May 2024

Recipient record

Reports, concerns and published responses

Justice · Prison or young offender institution. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 2
Published responses: 50%
Concerns addressed: 1
Stated actions: 4

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

50%published responses found

4stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Norwich Prison linked to the concerns in each report. Select any concern, action or position to view the source wording.

1 May2024
Norfolk
Concerns raised6
1. Failure to provide complete and relevant document disclosure
2. Failure to scan all document versions onto the electronic system
3. Failure to adequately investigate concerns about document authenticity
1. Existence of duplicate document versions without a complete record
2. Creation of documents bearing unauthorised signatures
3. Failure to identify retrospective entries and their reasons
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

Mohammed AMIN AZIZI · 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

Mohammed Azizi, who had Crohn’s disease and deep vein thrombosis, repeatedly refused food, monitoring, investigations and treatment while in prison and hospital. He died in hospital on 15 May 2023 from cardiac atrophy and failure, with contributing factors including malnutrition, Crohn’s disease, self-neglect and pulmonary thromboembolism and infarction. The principal concerns related to two versions of an ACCT document, apparent signatures that witnesses said they had not added, possible retrospective reconstruction of records, and incomplete disclosure to the court and the PPO.

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 Norwich Prison; that does not assign responsibility.
PFD Monitor interpretation
Failure to provide complete and relevant document disclosure
Wider context from the report
“There are also concerns about disclosure of documents and how it came to be that both the Court and the PPO received just one of 2 documents that existed for the same date, and that neither was advised of the concerns previously raised regarding the document that was disclosed. Had the Officer in question not been called to give evidence in Court and her statement simply read in to evidence, the Court would never have been aware of the existence of the second ACCT document, nor the issues surrounding it and nor would the PPO, which is of significant concern. The Court was not provided with evidence to explain how this occurred, who disclosed the document and why they only disclosed one, or how only one came to have been scanned on to the electronic system that was used to then provide disclosure. ”
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 Norwich Prison; that does not assign responsibility.
PFD Monitor interpretation
Failure to scan all document versions onto the electronic system
Wider context from the report
“There are also concerns about disclosure of documents and how it came to be that both the Court and the PPO received just one of 2 documents that existed for the same date, and that neither was advised of the concerns previously raised regarding the document that was disclosed. Had the Officer in question not been called to give evidence in Court and her statement simply read in to evidence, the Court would never have been aware of the existence of the second ACCT document, nor the issues surrounding it and nor would the PPO, which is of significant concern. The Court was not provided with evidence to explain how this occurred, who disclosed the document and why they only disclosed one, or how only one came to have been scanned on to the electronic system that was used to then provide disclosure. ”
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 Norwich Prison; that does not assign responsibility.
PFD Monitor interpretation
Failure to adequately investigate concerns about document authenticity
Wider context from the report
“The evidence was that any enquiries into the concern raised by the Officer in December 2023 were limited, as it was felt that it was simply a misunderstanding and some documents had been photocopied. We had the original documents in Court and both appear to have been hand written in pen and one is not a photocopy of anything else. The prison have been unable to provide an explanation as to when, how or by whom, the second document was created. ”
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 Norwich Prison; that does not assign responsibility.
PFD Monitor interpretation
Existence of duplicate document versions without a complete record
Wider context from the report
“It is unclear whether the two versions were in use at the same time. Both have sections completed by different Officers, which may suggest they were, although none of the witnesses who gave evidence were aware of this or had even been aware of this in their career. However, the existence of 2 documents, were it to happen, would also give rise to concern as no single document would contain a full and complete picture. ”
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 Norwich Prison; that does not assign responsibility.
PFD Monitor interpretation
Creation of documents bearing unauthorised signatures
Wider context from the report
“A document has been created, which two witnesses said under oath bears what appears to be their signatures, but both confirmed they did not in fact sign those 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 Norwich Prison; that does not assign responsibility.
PFD Monitor interpretation
Failure to identify retrospective entries and their reasons
Wider context from the report
“We also had evidence from another Officer who said that as part of a Quality Assurance review, she was asked to add notes to an ACCT document after it had been closed, she thought roughly six weeks later (that was to the document that the witnesses said had not been signed by them). This raises concern that an Officer was asked to recreate sections of a document and effectively back date them, without making it clear that this is a retrospective entry and for what reason. The Court was advised by Counsel for the prison that this system has changed, but there was no evidence from the prison to support this and confirm why this could not happen again. ”
Open source report
2 Feb2015
Norfolk
Concerns raised2
1. Failure to ensure Code Blue responders know where to go
2. Insufficient availability of recently CPR-trained Prison Officers for emergencies
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Train all permanent night staff to provide first-aid cover during nights and weekends.
  Stated completed
Respondent positions 1
1. Position
  Existing first-aid risk assessment, staffing levels, night cover and 24-hour healthcare are considered sufficient to address CPR response risks.
  Existing arrangements considered sufficient
AI-generated summary

DARREN WRIGHT · 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

Darren Wright, aged 35, was found dead in his cell at HMP Norwich on 3 November 2013 after having been admitted to prison in September 2013. The report identified concerns about inconsistent sharing and access to information, the response to a Code Blue notification, and gaps in recent CPR training among attending prison officers.

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 Norwich Prison; that does not assign responsibility.
PFD Monitor interpretation
Failure to ensure Code Blue responders know where to go
Wider context from the report
“(1) On receiving Code Blue notification the Staff Nurse did not know where to go and had to call on her radio to be found and then taken to the 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 Norwich Prison; that does not assign responsibility.
PFD Monitor interpretation
Insufficient availability of recently CPR-trained Prison Officers for emergencies
Wider context from the report
“(2) The Prison Officers attending Mr Wright had not had recent CPR training. It is understood that due to a lack of resources, CPR training has had to be allocated to certain members of staff only. This will result in gaps in CPR-trained Officers available and able to attend emergencies. ”
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Train all permanent night staff to provide first-aid cover during nights and weekends.

Verbatim wording from the response
“In addition to this, all our permanent night staff are trained to ensure adequate cover on nights and weekends.”

Source location
2015-0035-Response-by-Ministry-of-Justice
Page 2 · response
Published 2 February 2015
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Existing first-aid risk assessment, staffing levels, night cover and 24-hour healthcare are considered sufficient to address CPR response risks.

Verbatim wording from the response
“Those in charge of NOMS premises are required to carry out a risk assessment of the first aid needs for their prison. HMP/YOI Norwich has such an assessment in place which takes into account:”

Source location
2015-0035-Response-by-Ministry-of-Justice
Page 1 · response
Published 2 February 2015
Open published response

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised6

Failure to provide complete and relevant document disclosure

Failure to scan all document versions onto the electronic system

Failure to adequately investigate concerns about document authenticity

Existence of duplicate document versions without a complete record

Creation of documents bearing unauthorised signatures

Failure to identify retrospective entries and their reasons

Concerns raised2

Failure to ensure Code Blue responders know where to go

Insufficient availability of recently CPR-trained Prison Officers for emergencies

Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised.1

Respondent positions A position is what this recipient says about the concern when it does not describe a specific action.1

Actions described in response 1

Respondent positions 1