30 Mar 2026 Rickie Wai Kee POON · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 12 Premature closure of ACCT processes View source ACCT reviews lacking structure and consistency View source Inappropriate reduction of ACCT observations View source Failure to complete handovers between ACCT staff View source Failure to implement and follow up agreed ACCT actions View source Expired ACCT training View source Failure to read or follow up important ACCT-related emails View source Less-than-fully-competent CPR attempts View source Failure of supervising officers to acquaint themselves with case notes or history when completing ACCT reviews View source Inaccurate ACCT sign-offs View source Over-reliance of prison staff on a single presentation for ACCT knowledge View source Inadequate ACCT record keeping View source See 9 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
Rickie Wai Kee POON · 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
Rickie Poon, a dismissed police officer detained under the Mental Health Act and later remanded in custody at HMP Pentonville, was found hanging in his cell one month after arriving at the prison. The jury found failures in the prison’s ACCT process contributed to his death, including inadequate management, accountability, training, implementation of actions and the early closure of the ACCT; concerns were also raised about inappropriate CPR after he had died.
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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Premature closure of ACCT processes
Wider context from the report “The jury found that the following failures at HMP Pentonville in the ACCT (assessment care in custody and teamwork) process contributed to Mr Poon’s death:
• the ACCT process was not managed and implemented properly, e.g. supervising officers did not consistently acquaint themselves with case notes or history when completing reviews; record keeping was inadequate; agreed actions were not consistently implemented; and ACCT reviews lacked structure and consistency;
• accountability was insufficient, e.g. there was no follow up when actions were missed in the ACCT document, sign offs were completed inaccurately, hand overs were not completed between staff, and an important email was not read or followed up on;
• there were gaps in training and knowledge, e.g. ACCT training had expired and prison staff overly relied on Rickie’s presentation;
• the ACCT was closed too soon .
The jury also found that the level of ACCT observations was reduced inappropriately, but they were unclear as to whether this impacted on the outcome.
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation ACCT reviews lacking structure and consistency
Wider context from the report “The jury found that the following failures at HMP Pentonville in the ACCT (assessment care in custody and teamwork) process contributed to Mr Poon’s death:
• the ACCT process was not managed and implemented properly, e.g. supervising officers did not consistently acquaint themselves with case notes or history when completing reviews; record keeping was inadequate; agreed actions were not consistently implemented; and ACCT reviews lacked structure and consistency ;
• accountability was insufficient, e.g. there was no follow up when actions were missed in the ACCT document, sign offs were completed inaccurately, hand overs were not completed between staff, and an important email was not read or followed up on;
• there were gaps in training and knowledge, e.g. ACCT training had expired and prison staff overly relied on Rickie’s presentation;
• the ACCT was closed too soon.
The jury also found that the level of ACCT observations was reduced inappropriately, but they were unclear as to whether this impacted on the outcome.
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Inappropriate reduction of ACCT observations
Wider context from the report “The jury found that the following failures at HMP Pentonville in the ACCT (assessment care in custody and teamwork) process contributed to Mr Poon’s death:
• the ACCT process was not managed and implemented properly, e.g. supervising officers did not consistently acquaint themselves with case notes or history when completing reviews; record keeping was inadequate; agreed actions were not consistently implemented; and ACCT reviews lacked structure and consistency;
• accountability was insufficient, e.g. there was no follow up when actions were missed in the ACCT document, sign offs were completed inaccurately, hand overs were not completed between staff, and an important email was not read or followed up on;
• there were gaps in training and knowledge, e.g. ACCT training had expired and prison staff overly relied on Rickie’s presentation;
• the ACCT was closed too soon.
The jury also found that the level of ACCT observations was reduced inappropriately , but they were unclear as to whether this impacted on the outcome.
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to complete handovers between ACCT staff
Wider context from the report “The jury found that the following failures at HMP Pentonville in the ACCT (assessment care in custody and teamwork) process contributed to Mr Poon’s death:
• the ACCT process was not managed and implemented properly, e.g. supervising officers did not consistently acquaint themselves with case notes or history when completing reviews; record keeping was inadequate; agreed actions were not consistently implemented; and ACCT reviews lacked structure and consistency;
• accountability was insufficient, e.g. there was no follow up when actions were missed in the ACCT document, sign offs were completed inaccurately, hand overs were not completed between staff , and an important email was not read or followed up on;
• there were gaps in training and knowledge, e.g. ACCT training had expired and prison staff overly relied on Rickie’s presentation;
• the ACCT was closed too soon.
The jury also found that the level of ACCT observations was reduced inappropriately, but they were unclear as to whether this impacted on the outcome.
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to implement and follow up agreed ACCT actions
Wider context from the report “The jury found that the following failures at HMP Pentonville in the ACCT (assessment care in custody and teamwork) process contributed to Mr Poon’s death:
• the ACCT process was not managed and implemented properly, e.g. supervising officers did not consistently acquaint themselves with case notes or history when completing reviews; record keeping was inadequate; agreed actions were not consistently implemented ; and ACCT reviews lacked structure and consistency;
• accountability was insufficient, e.g. there was no follow up when actions were missed in the ACCT document , sign offs were completed inaccurately, hand overs were not completed between staff, and an important email was not read or followed up on;
• there were gaps in training and knowledge, e.g. ACCT training had expired and prison staff overly relied on Rickie’s presentation;
• the ACCT was closed too soon.
The jury also found that the level of ACCT observations was reduced inappropriately, but they were unclear as to whether this impacted on the outcome.
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Expired ACCT training
Wider context from the report “The jury found that the following failures at HMP Pentonville in the ACCT (assessment care in custody and teamwork) process contributed to Mr Poon’s death:
• the ACCT process was not managed and implemented properly, e.g. supervising officers did not consistently acquaint themselves with case notes or history when completing reviews; record keeping was inadequate; agreed actions were not consistently implemented; and ACCT reviews lacked structure and consistency;
• accountability was insufficient, e.g. there was no follow up when actions were missed in the ACCT document, sign offs were completed inaccurately, hand overs were not completed between staff, and an important email was not read or followed up on;
• there were gaps in training and knowledge , e.g. ACCT training had expired and prison staff overly relied on Rickie’s presentation;
• the ACCT was closed too soon.
The jury also found that the level of ACCT observations was reduced inappropriately, but they were unclear as to whether this impacted on the outcome.
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to read or follow up important ACCT-related emails
Wider context from the report “The jury found that the following failures at HMP Pentonville in the ACCT (assessment care in custody and teamwork) process contributed to Mr Poon’s death:
• the ACCT process was not managed and implemented properly, e.g. supervising officers did not consistently acquaint themselves with case notes or history when completing reviews; record keeping was inadequate; agreed actions were not consistently implemented; and ACCT reviews lacked structure and consistency;
• accountability was insufficient, e.g. there was no follow up when actions were missed in the ACCT document, sign offs were completed inaccurately, hand overs were not completed between staff, and an important email was not read or followed up on ;
• there were gaps in training and knowledge, e.g. ACCT training had expired and prison staff overly relied on Rickie’s presentation;
• the ACCT was closed too soon.
The jury also found that the level of ACCT observations was reduced inappropriately, but they were unclear as to whether this impacted on the outcome.
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Less-than-fully-competent CPR attempts
Wider context from the report “The nurse’s actions could not have had an impact on the outcome because Mr Poon was already dead when she arrived. However, conducting CPR on a person who had clearly died was not professional or appropriate, it did not afford Mr Poon dignity or privacy, it was neither acceptable nor kind.
What concerns me particularly for the future is that there might be an occasion when a CPR attempt that is less than fully competent does have the potential to impact on the outcome .
I sent PFD reports to PPG’s earlier incarnation, Care UK, and/or HMP Pentonville about the nature of attempts at resuscitation in respect of the following deceased:
• William Davies (2014)
• Adil Habib (2015)
• Samuel Blair (2016)
• Tedros Kahssay (2016)
• Amir Faizi (2018)
• Robert Ginn (2019)
I recognise that I made the last of these reports over six years ago and I have heard descriptions of many changes since then, but I consider that I would be failing in my duty if I were not to flag up this issue now. I hope that by doing so, such a situation will be less likely to arise in the future.
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure of supervising officers to acquaint themselves with case notes or history when completing ACCT reviews
Wider context from the report “The jury found that the following failures at HMP Pentonville in the ACCT (assessment care in custody and teamwork) process contributed to Mr Poon’s death:
• the ACCT process was not managed and implemented properly, e.g. supervising officers did not consistently acquaint themselves with case notes or history when completing reviews ; record keeping was inadequate; agreed actions were not consistently implemented; and ACCT reviews lacked structure and consistency;
• accountability was insufficient, e.g. there was no follow up when actions were missed in the ACCT document, sign offs were completed inaccurately, hand overs were not completed between staff, and an important email was not read or followed up on;
• there were gaps in training and knowledge, e.g. ACCT training had expired and prison staff overly relied on Rickie’s presentation;
• the ACCT was closed too soon.
The jury also found that the level of ACCT observations was reduced inappropriately, but they were unclear as to whether this impacted on the outcome.
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Inaccurate ACCT sign-offs
Wider context from the report “The jury found that the following failures at HMP Pentonville in the ACCT (assessment care in custody and teamwork) process contributed to Mr Poon’s death:
• the ACCT process was not managed and implemented properly, e.g. supervising officers did not consistently acquaint themselves with case notes or history when completing reviews; record keeping was inadequate; agreed actions were not consistently implemented; and ACCT reviews lacked structure and consistency;
• accountability was insufficient, e.g. there was no follow up when actions were missed in the ACCT document, sign offs were completed inaccurately , hand overs were not completed between staff, and an important email was not read or followed up on;
• there were gaps in training and knowledge, e.g. ACCT training had expired and prison staff overly relied on Rickie’s presentation;
• the ACCT was closed too soon.
The jury also found that the level of ACCT observations was reduced inappropriately, but they were unclear as to whether this impacted on the outcome.
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Over-reliance of prison staff on a single presentation for ACCT knowledge
Wider context from the report “The jury found that the following failures at HMP Pentonville in the ACCT (assessment care in custody and teamwork) process contributed to Mr Poon’s death:
• the ACCT process was not managed and implemented properly, e.g. supervising officers did not consistently acquaint themselves with case notes or history when completing reviews; record keeping was inadequate; agreed actions were not consistently implemented; and ACCT reviews lacked structure and consistency;
• accountability was insufficient, e.g. there was no follow up when actions were missed in the ACCT document, sign offs were completed inaccurately, hand overs were not completed between staff, and an important email was not read or followed up on;
• there were gaps in training and knowledge, e.g. ACCT training had expired and prison staff overly relied on Rickie’s presentation ;
• the ACCT was closed too soon.
The jury also found that the level of ACCT observations was reduced inappropriately, but they were unclear as to whether this impacted on the outcome.
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Inadequate ACCT record keeping
Wider context from the report “The jury found that the following failures at HMP Pentonville in the ACCT (assessment care in custody and teamwork) process contributed to Mr Poon’s death:
• the ACCT process was not managed and implemented properly, e.g. supervising officers did not consistently acquaint themselves with case notes or history when completing reviews; record keeping was inadequate ; agreed actions were not consistently implemented; and ACCT reviews lacked structure and consistency;
• accountability was insufficient, e.g. there was no follow up when actions were missed in the ACCT document, sign offs were completed inaccurately, hand overs were not completed between staff, and an important email was not read or followed up on;
• there were gaps in training and knowledge, e.g. ACCT training had expired and prison staff overly relied on Rickie’s presentation;
• the ACCT was closed too soon.
The jury also found that the level of ACCT observations was reduced inappropriately, but they were unclear as to whether this impacted on the outcome.
” Open source report
11 Mar 2026 Peter Asher CAMPBELL · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 9 Failure to prevent drugs from entering the prison View source Failure to follow up when recovery-worker engagement is ineffective View source Failure to conduct recovery-worker interactions privately View source Failure of post-incident investigations to identify gaps in drug recovery care View source Failure to have meaningful discussions about prisoners’ drug use View source Harm-minimisation guidance failing to address risks to cellmates View source Failure to review medical records before recovery-worker interactions View source Failure of routine supervision or audit to identify gaps in drug recovery care View source Failure to ensure recovery-worker practice complies with training View source See 6 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
Peter Asher CAMPBELL · 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
Peter Asher Campbell collapsed in his prison cell at Pentonville after smoking a drug and died five days later. The principal concerns were the failure to prevent drugs entering the prison and shortcomings in the prison drug service’s response, including inadequate engagement, harm-minimisation advice, staff training, supervision and auditing.
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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent drugs from entering the prison
Wider context from the report “For HMPPS and Pentonville
In the narrative conclusion, the jury recorded a failure to prevent drugs from entering the prison .
Every witness at inquest who expressed a view gave evidence that drugs are rife within Pentonville, as they are across the prison estate. They enter attached to drones and in throw overs; via prison officers, visitors and prisoners; and, to a lesser extent these days, in the post. ████████, a drug many times more potent and dangerous than cannabis, ████████ It has infiltrated the prison population with enormous reach and with potentially devastating consequences for the prisoners themselves and for others - there is a risk of prisoners leaving prison in a worse state than when they went in, a state that may of course be reflected in violent reoffending.
Initially, I was not going to include that failure within my prevention of future deaths report, because the availability of drugs in prison seems such a huge and intractable problem. However, on reflection it seems to me that it would be complacent to view the size of the problem as prohibitive. Perhaps the size of the problem dictates only the size of the solution required.
At inquest, I heard about other aspects of the prison regime that were sub optimal, but it appeared that since Mr Campbell’s death, the staff at Pentonville had taken steps to address these.
However, the mass availability of drugs apparently persists without abatement . This is not in any way peculiar to Pentonville, but Pentonville is an exemplar.
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to follow up when recovery-worker engagement is ineffective
Wider context from the report “For Phoenix and PPG
Mr Campbell collapsed in prison on 18 September 2024 as he had done before following the use of ████████, and the prison and healthcare staff responded to this as an emergency code blue. The ambulance service was called and he was immediately conveyed to hospital where he was resuscitated.
The jury found a failure by the prison drug service to provide a meaningful interaction with Mr Campbell between the collapse on 18 September 2024 and the fatal collapse on 3 October 2024. This was partly because a visit was not arranged promptly, a systemic issue that since seems to have been addressed.
However, I also heard evidence that, when the Phoenix recovery worker did go to see Mr Campbell on 1 October 2024 in an attempt to promote harm minimisation:
• She did not read any part of his medical records before she saw him, and she did not know whether she was meant to do so. She was.
• She spoke to him through the hatch in the cell door, with his cellmate present. This was her normal practice, but she was not able to say why. It should not have been.
• She did not have any meaningful discussion with him about his drug use, either the use that led to his collapse on 18 September 2024 or his use generally. She should have.
• She gave him various pieces of harm minimisation guidance in keeping with her training, including the advice to avoid using drugs whilst alone. This advice was later confirmed as within policy by the Phoenix head of service. However, it does not seem to take account of the fact that smoking a drug in a small cell with a cellmate puts the cellmate at risk.
• Mr Campbell told her that he was not under the influence at the time. The recovery worker was not wholly convinced, but she did not return later that day or the following day to see if better engagement was possible . She should have.
• She did not know whether her interaction with Mr Campbell was in accordance with her training. I was told that it was not. She had not received further training or changed her practice since his death.
• The drug recovery worker was the last healthcare worker to see Mr Campbell before his fatal collapse from drugs and did so just two days before that occurred. However, the gaps in her care of Mr Campbell were not identified by the investigation following his death by Phoenix and PPG (or by the Prisons and Probation Ombudsman).
• She had not changed her practice since Mr Campbell’s death, but any gaps in her care of other prisoners had also not been identified in the following year and a half, either by routine supervision or by audit. I heard that audits are undertaken of the medical records only.
Therefore, the first time that Phoenix and PPG recognised a drug recovery worker’s failures to follow their procedures over at least a year and a half, was at the inquest.
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct recovery-worker interactions privately
Wider context from the report “For Phoenix and PPG
Mr Campbell collapsed in prison on 18 September 2024 as he had done before following the use of ████████, and the prison and healthcare staff responded to this as an emergency code blue. The ambulance service was called and he was immediately conveyed to hospital where he was resuscitated.
The jury found a failure by the prison drug service to provide a meaningful interaction with Mr Campbell between the collapse on 18 September 2024 and the fatal collapse on 3 October 2024. This was partly because a visit was not arranged promptly, a systemic issue that since seems to have been addressed.
However, I also heard evidence that, when the Phoenix recovery worker did go to see Mr Campbell on 1 October 2024 in an attempt to promote harm minimisation:
• She did not read any part of his medical records before she saw him, and she did not know whether she was meant to do so. She was.
• She spoke to him through the hatch in the cell door, with his cellmate present . This was her normal practice , but she was not able to say why. It should not have been.
• She did not have any meaningful discussion with him about his drug use, either the use that led to his collapse on 18 September 2024 or his use generally. She should have.
• She gave him various pieces of harm minimisation guidance in keeping with her training, including the advice to avoid using drugs whilst alone. This advice was later confirmed as within policy by the Phoenix head of service. However, it does not seem to take account of the fact that smoking a drug in a small cell with a cellmate puts the cellmate at risk.
• Mr Campbell told her that he was not under the influence at the time. The recovery worker was not wholly convinced, but she did not return later that day or the following day to see if better engagement was possible. She should have.
• She did not know whether her interaction with Mr Campbell was in accordance with her training. I was told that it was not. She had not received further training or changed her practice since his death.
• The drug recovery worker was the last healthcare worker to see Mr Campbell before his fatal collapse from drugs and did so just two days before that occurred. However, the gaps in her care of Mr Campbell were not identified by the investigation following his death by Phoenix and PPG (or by the Prisons and Probation Ombudsman).
• She had not changed her practice since Mr Campbell’s death, but any gaps in her care of other prisoners had also not been identified in the following year and a half, either by routine supervision or by audit. I heard that audits are undertaken of the medical records only.
Therefore, the first time that Phoenix and PPG recognised a drug recovery worker’s failures to follow their procedures over at least a year and a half, was at the inquest.
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure of post-incident investigations to identify gaps in drug recovery care
Wider context from the report “For Phoenix and PPG
Mr Campbell collapsed in prison on 18 September 2024 as he had done before following the use of ████████, and the prison and healthcare staff responded to this as an emergency code blue. The ambulance service was called and he was immediately conveyed to hospital where he was resuscitated.
The jury found a failure by the prison drug service to provide a meaningful interaction with Mr Campbell between the collapse on 18 September 2024 and the fatal collapse on 3 October 2024. This was partly because a visit was not arranged promptly, a systemic issue that since seems to have been addressed.
However, I also heard evidence that, when the Phoenix recovery worker did go to see Mr Campbell on 1 October 2024 in an attempt to promote harm minimisation:
• She did not read any part of his medical records before she saw him, and she did not know whether she was meant to do so. She was.
• She spoke to him through the hatch in the cell door, with his cellmate present. This was her normal practice, but she was not able to say why. It should not have been.
• She did not have any meaningful discussion with him about his drug use, either the use that led to his collapse on 18 September 2024 or his use generally. She should have.
• She gave him various pieces of harm minimisation guidance in keeping with her training, including the advice to avoid using drugs whilst alone. This advice was later confirmed as within policy by the Phoenix head of service. However, it does not seem to take account of the fact that smoking a drug in a small cell with a cellmate puts the cellmate at risk.
• Mr Campbell told her that he was not under the influence at the time. The recovery worker was not wholly convinced, but she did not return later that day or the following day to see if better engagement was possible. She should have.
• She did not know whether her interaction with Mr Campbell was in accordance with her training. I was told that it was not. She had not received further training or changed her practice since his death.
• The drug recovery worker was the last healthcare worker to see Mr Campbell before his fatal collapse from drugs and did so just two days before that occurred. However, the gaps in her care of Mr Campbell were not identified by the investigation following his death by Phoenix and PPG (or by the Prisons and Probation Ombudsman).
• She had not changed her practice since Mr Campbell’s death, but any gaps in her care of other prisoners had also not been identified in the following year and a half, either by routine supervision or by audit. I heard that audits are undertaken of the medical records only.
Therefore, the first time that Phoenix and PPG recognised a drug recovery worker’s failures to follow their procedures over at least a year and a half, was at the inquest.
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to have meaningful discussions about prisoners’ drug use
Wider context from the report “For Phoenix and PPG
Mr Campbell collapsed in prison on 18 September 2024 as he had done before following the use of ████████, and the prison and healthcare staff responded to this as an emergency code blue. The ambulance service was called and he was immediately conveyed to hospital where he was resuscitated.
The jury found a failure by the prison drug service to provide a meaningful interaction with Mr Campbell between the collapse on 18 September 2024 and the fatal collapse on 3 October 2024. This was partly because a visit was not arranged promptly, a systemic issue that since seems to have been addressed.
However, I also heard evidence that, when the Phoenix recovery worker did go to see Mr Campbell on 1 October 2024 in an attempt to promote harm minimisation:
• She did not read any part of his medical records before she saw him, and she did not know whether she was meant to do so. She was.
• She spoke to him through the hatch in the cell door, with his cellmate present. This was her normal practice, but she was not able to say why. It should not have been.
• She did not have any meaningful discussion with him about his drug use , either the use that led to his collapse on 18 September 2024 or his use generally. She should have.
• She gave him various pieces of harm minimisation guidance in keeping with her training, including the advice to avoid using drugs whilst alone. This advice was later confirmed as within policy by the Phoenix head of service. However, it does not seem to take account of the fact that smoking a drug in a small cell with a cellmate puts the cellmate at risk.
• Mr Campbell told her that he was not under the influence at the time. The recovery worker was not wholly convinced, but she did not return later that day or the following day to see if better engagement was possible. She should have.
• She did not know whether her interaction with Mr Campbell was in accordance with her training. I was told that it was not. She had not received further training or changed her practice since his death.
• The drug recovery worker was the last healthcare worker to see Mr Campbell before his fatal collapse from drugs and did so just two days before that occurred. However, the gaps in her care of Mr Campbell were not identified by the investigation following his death by Phoenix and PPG (or by the Prisons and Probation Ombudsman).
• She had not changed her practice since Mr Campbell’s death, but any gaps in her care of other prisoners had also not been identified in the following year and a half, either by routine supervision or by audit. I heard that audits are undertaken of the medical records only.
Therefore, the first time that Phoenix and PPG recognised a drug recovery worker’s failures to follow their procedures over at least a year and a half, was at the inquest.
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Harm-minimisation guidance failing to address risks to cellmates
Wider context from the report “For Phoenix and PPG
Mr Campbell collapsed in prison on 18 September 2024 as he had done before following the use of ████████, and the prison and healthcare staff responded to this as an emergency code blue. The ambulance service was called and he was immediately conveyed to hospital where he was resuscitated.
The jury found a failure by the prison drug service to provide a meaningful interaction with Mr Campbell between the collapse on 18 September 2024 and the fatal collapse on 3 October 2024. This was partly because a visit was not arranged promptly, a systemic issue that since seems to have been addressed.
However, I also heard evidence that, when the Phoenix recovery worker did go to see Mr Campbell on 1 October 2024 in an attempt to promote harm minimisation:
• She did not read any part of his medical records before she saw him, and she did not know whether she was meant to do so. She was.
• She spoke to him through the hatch in the cell door, with his cellmate present. This was her normal practice, but she was not able to say why. It should not have been.
• She did not have any meaningful discussion with him about his drug use, either the use that led to his collapse on 18 September 2024 or his use generally. She should have.
• She gave him various pieces of harm minimisation guidance in keeping with her training, including the advice to avoid using drugs whilst alone. This advice was later confirmed as within policy by the Phoenix head of service. However, it does not seem to take account of the fact that smoking a drug in a small cell with a cellmate puts the cellmate at risk .
• Mr Campbell told her that he was not under the influence at the time. The recovery worker was not wholly convinced, but she did not return later that day or the following day to see if better engagement was possible. She should have.
• She did not know whether her interaction with Mr Campbell was in accordance with her training. I was told that it was not. She had not received further training or changed her practice since his death.
• The drug recovery worker was the last healthcare worker to see Mr Campbell before his fatal collapse from drugs and did so just two days before that occurred. However, the gaps in her care of Mr Campbell were not identified by the investigation following his death by Phoenix and PPG (or by the Prisons and Probation Ombudsman).
• She had not changed her practice since Mr Campbell’s death, but any gaps in her care of other prisoners had also not been identified in the following year and a half, either by routine supervision or by audit. I heard that audits are undertaken of the medical records only.
Therefore, the first time that Phoenix and PPG recognised a drug recovery worker’s failures to follow their procedures over at least a year and a half, was at the inquest.
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to review medical records before recovery-worker interactions
Wider context from the report “For Phoenix and PPG
Mr Campbell collapsed in prison on 18 September 2024 as he had done before following the use of ████████, and the prison and healthcare staff responded to this as an emergency code blue. The ambulance service was called and he was immediately conveyed to hospital where he was resuscitated.
The jury found a failure by the prison drug service to provide a meaningful interaction with Mr Campbell between the collapse on 18 September 2024 and the fatal collapse on 3 October 2024. This was partly because a visit was not arranged promptly, a systemic issue that since seems to have been addressed.
However, I also heard evidence that, when the Phoenix recovery worker did go to see Mr Campbell on 1 October 2024 in an attempt to promote harm minimisation:
• She did not read any part of his medical records before she saw him , and she did not know whether she was meant to do so . She was.
• She spoke to him through the hatch in the cell door, with his cellmate present. This was her normal practice, but she was not able to say why. It should not have been.
• She did not have any meaningful discussion with him about his drug use, either the use that led to his collapse on 18 September 2024 or his use generally. She should have.
• She gave him various pieces of harm minimisation guidance in keeping with her training, including the advice to avoid using drugs whilst alone. This advice was later confirmed as within policy by the Phoenix head of service. However, it does not seem to take account of the fact that smoking a drug in a small cell with a cellmate puts the cellmate at risk.
• Mr Campbell told her that he was not under the influence at the time. The recovery worker was not wholly convinced, but she did not return later that day or the following day to see if better engagement was possible. She should have.
• She did not know whether her interaction with Mr Campbell was in accordance with her training. I was told that it was not. She had not received further training or changed her practice since his death.
• The drug recovery worker was the last healthcare worker to see Mr Campbell before his fatal collapse from drugs and did so just two days before that occurred. However, the gaps in her care of Mr Campbell were not identified by the investigation following his death by Phoenix and PPG (or by the Prisons and Probation Ombudsman).
• She had not changed her practice since Mr Campbell’s death, but any gaps in her care of other prisoners had also not been identified in the following year and a half, either by routine supervision or by audit. I heard that audits are undertaken of the medical records only.
Therefore, the first time that Phoenix and PPG recognised a drug recovery worker’s failures to follow their procedures over at least a year and a half, was at the inquest.
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure of routine supervision or audit to identify gaps in drug recovery care
Wider context from the report “For Phoenix and PPG
Mr Campbell collapsed in prison on 18 September 2024 as he had done before following the use of ████████, and the prison and healthcare staff responded to this as an emergency code blue. The ambulance service was called and he was immediately conveyed to hospital where he was resuscitated.
The jury found a failure by the prison drug service to provide a meaningful interaction with Mr Campbell between the collapse on 18 September 2024 and the fatal collapse on 3 October 2024. This was partly because a visit was not arranged promptly, a systemic issue that since seems to have been addressed.
However, I also heard evidence that, when the Phoenix recovery worker did go to see Mr Campbell on 1 October 2024 in an attempt to promote harm minimisation:
• She did not read any part of his medical records before she saw him, and she did not know whether she was meant to do so. She was.
• She spoke to him through the hatch in the cell door, with his cellmate present. This was her normal practice, but she was not able to say why. It should not have been.
• She did not have any meaningful discussion with him about his drug use, either the use that led to his collapse on 18 September 2024 or his use generally. She should have.
• She gave him various pieces of harm minimisation guidance in keeping with her training, including the advice to avoid using drugs whilst alone. This advice was later confirmed as within policy by the Phoenix head of service. However, it does not seem to take account of the fact that smoking a drug in a small cell with a cellmate puts the cellmate at risk.
• Mr Campbell told her that he was not under the influence at the time. The recovery worker was not wholly convinced, but she did not return later that day or the following day to see if better engagement was possible. She should have.
• She did not know whether her interaction with Mr Campbell was in accordance with her training. I was told that it was not. She had not received further training or changed her practice since his death.
• The drug recovery worker was the last healthcare worker to see Mr Campbell before his fatal collapse from drugs and did so just two days before that occurred. However, the gaps in her care of Mr Campbell were not identified by the investigation following his death by Phoenix and PPG (or by the Prisons and Probation Ombudsman).
• She had not changed her practice since Mr Campbell’s death, but any gaps in her care of other prisoners had also not been identified in the following year and a half, either by routine supervision or by audit . I heard that audits are undertaken of the medical records only .
Therefore, the first time that Phoenix and PPG recognised a drug recovery worker’s failures to follow their procedures over at least a year and a half, was at the inquest.
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure recovery-worker practice complies with training
Wider context from the report “For Phoenix and PPG
Mr Campbell collapsed in prison on 18 September 2024 as he had done before following the use of ████████, and the prison and healthcare staff responded to this as an emergency code blue. The ambulance service was called and he was immediately conveyed to hospital where he was resuscitated.
The jury found a failure by the prison drug service to provide a meaningful interaction with Mr Campbell between the collapse on 18 September 2024 and the fatal collapse on 3 October 2024. This was partly because a visit was not arranged promptly, a systemic issue that since seems to have been addressed.
However, I also heard evidence that, when the Phoenix recovery worker did go to see Mr Campbell on 1 October 2024 in an attempt to promote harm minimisation:
• She did not read any part of his medical records before she saw him, and she did not know whether she was meant to do so. She was.
• She spoke to him through the hatch in the cell door, with his cellmate present. This was her normal practice, but she was not able to say why. It should not have been.
• She did not have any meaningful discussion with him about his drug use, either the use that led to his collapse on 18 September 2024 or his use generally. She should have.
• She gave him various pieces of harm minimisation guidance in keeping with her training, including the advice to avoid using drugs whilst alone. This advice was later confirmed as within policy by the Phoenix head of service. However, it does not seem to take account of the fact that smoking a drug in a small cell with a cellmate puts the cellmate at risk.
• Mr Campbell told her that he was not under the influence at the time. The recovery worker was not wholly convinced, but she did not return later that day or the following day to see if better engagement was possible. She should have.
• She did not know whether her interaction with Mr Campbell was in accordance with her training . I was told that it was not . She had not received further training or changed her practice since his death .
• The drug recovery worker was the last healthcare worker to see Mr Campbell before his fatal collapse from drugs and did so just two days before that occurred. However, the gaps in her care of Mr Campbell were not identified by the investigation following his death by Phoenix and PPG (or by the Prisons and Probation Ombudsman).
• She had not changed her practice since Mr Campbell’s death, but any gaps in her care of other prisoners had also not been identified in the following year and a half, either by routine supervision or by audit. I heard that audits are undertaken of the medical records only.
Therefore, the first time that Phoenix and PPG recognised a drug recovery worker’s failures to follow their procedures over at least a year and a half, was at the inquest.
” Open source report
3 Mar 2026 Mujahid Adam · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 4 Failure to record 15-minute observations contemporaneously and accurately View source Lack of a clear definition and procedure for 15-minute observations View source Failure to maintain special cells in a condition that prevents access to ligature-making material View source Failure of daily accommodation and fabric checks to identify disrepair in special cells 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
Mujahid Adam · 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
Mujahid Adam died by suicide after being found hanging in his prison cell on 15 March 2025; he was declared dead on 21 March 2025 at University College Hospital. The concerns included inadequate and non-contemporaneous recording of 15-minute observations, no clear definition of what constituted an observation, delays in calling Code Blue and cutting him down, and disrepair in the cell that allowed access to ligature material.
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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to record 15-minute observations contemporaneously and accurately
Wider context from the report “(a) The recording of observations of 15-minute checks is not contemporaneous and is prone to inaccuracy . It relies on a prison officer walking from the cell to the wing office to record observations, every 15 minutes, which may not be realistic if a prisoner has other duties to perform ;
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear definition and procedure for 15-minute observations
Wider context from the report “(b) There is no clear definition of what constitutes an “observation” and how this should be done by staff at the prison when someone is on 15-minute observations ;
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain special cells in a condition that prevents access to ligature-making material
Wider context from the report “(c) The cell occupied by Mr Adam is one of a handful of special cells in the prison which are used for vulnerable prisoners on constant watch or on 15-minute observation. It was in a state of disrepair and gave access to the hidden material from which a ligature could be made . Despite daily AFCs, that disrepair was not noted although this was a special 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure of daily accommodation and fabric checks to identify disrepair in special cells
Wider context from the report “(c) The cell occupied by Mr Adam is one of a handful of special cells in the prison which are used for vulnerable prisoners on constant watch or on 15-minute observation. It was in a state of disrepair and gave access to the hidden material from which a ligature could be made. Despite daily AFCs, that disrepair was not noted although this was a special cell .
” Open source report
9 Feb 2026 Gareth Chumber-Kelly · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 4 Inefficiency and slowness of the prison reception process View source Failure to provide suicide and self-harm risk management training to prison officers View source Failure to provide regular mandatory basic life support training to prison officers View source Failure to retain documentation accompanying prisoners during reception 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
Gareth Chumber-Kelly · 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
Gareth Chumber-Kelly died after hanging himself while in custody at HMP Pentonville on 17 July 2023. The report identified concerns about lost or incomplete transfer documentation, inadequate recognition and management of suicide and self-harm risks, insufficient staff training, failures to provide basic life support, and inadequate staffing and support during crucial periods.
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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Inefficiency and slowness of the prison reception process
Wider context from the report “(1) The court heard evidence from prison staff that the reception process at HMP Pentonville was inefficient and slow and that paperwork would be sometimes be lost. This creates a risk to the safety and well-being of prisoners as the documentation accompanying the prisoner as they are conveyed to prison may contain (as was the case with Mr Chumber-Kelly) very important information about the prisoners which is relevant to ensuring all appropriate steps and measures are put in place to protect them. The Governor at HMP Pentonville told the court that no steps have been taken to address this recurrent problem , and the risk of important documentation being lost, and there has been no dialogue with Serco to address this issue.
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to provide suicide and self-harm risk management training to prison officers
Wider context from the report “(2) The court heard evidence that 2 prisoners had died by ligature suspension (on 17.6.2021 and 1.3.22) prior to Mr Chumber-Kelly’s death, and that since then a further 5 prisoners have died by ligature suspension (one of which was Mr Chumber-Kelly). The Governor of HMP Pentonville told the court that Suicide and Self harm training for prison staff had been suspended during Covid and had never been re-started notwithstanding that 38% of prisoners arriving at HMP Pentonville said they felt suicidal and notwithstanding that 7 prisoners have died by ligature suspension since June 2021. The failure to train prison officers in the risks and management of suicide and self-harm creates a risk of future deaths .
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to provide regular mandatory basic life support training to prison officers
Wider context from the report “(3) The court heard evidence that the first two officers on the scene failed to provide any form of basic life support despite having received training on how to do so. Both officers described how they panicked and did not know what to do. The court heard evidence from a consultant paramedic from the London Ambulance service with extensive experience in resuscitation who explained that for every minute without CPR there is a 10-22% drop in survival rates. It is critically important that the first person on the scene in such emergency situations (who will almost always be the prison officers) are properly and regularly trained in basic life support so that they are able to render such aid immediately on arrival. The Governor of the prison told the court that no refresher CPR training had been provided to prison staff since 2023 notwithstanding the 5 deaths of prisoners by ligature suspension that have occurred since. This is deeply concerning given that this very same issue was raised in a Prevention of Future Deaths Report by Mary Hassell, HM Senior Coroner of Inner North London on 18th September 2023 relating to the death of Amarjit Singh and yet in the 2 years since that PFD was issued there is still no mandatory basic life support training for prison officers .
The failure of the prison to provide regular, mandatory basic life support to all prison officer creates a risk of future deaths.
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to retain documentation accompanying prisoners during reception
Wider context from the report “(1) The court heard evidence from prison staff that the reception process at HMP Pentonville was inefficient and slow and that paperwork would be sometimes be lost . This creates a risk to the safety and well-being of prisoners as the documentation accompanying the prisoner as they are conveyed to prison may contain (as was the case with Mr Chumber-Kelly) very important information about the prisoners which is relevant to ensuring all appropriate steps and measures are put in place to protect them. The Governor at HMP Pentonville told the court that no steps have been taken to address this recurrent problem, and the risk of important documentation being lost , and there has been no dialogue with Serco to address this issue.
” Open source report
18 Sep 2023 Amarjit SINGH · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 5 Careless completion of cell sharing risk assessments View source Lack of seizure-response training for prison staff View source Unavailability of guidance for prisoners responding to a cellmate’s fit View source Lack of ongoing first aid training for prison officers View source Low first aid understanding among prison officers View source See 2 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
Amarjit SINGH · 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
Amarjit Singh, aged 41, was found dead in his cell at HMP Pentonville on the morning of 21 November 2021 after his cellmate reported that he had suffered a fit, but medical attention was not sought and the cell door remained locked. The inquest jury determined that he died from natural causes, contributed to by neglect. Outstanding concerns included a careless cell-sharing risk assessment and gaps in prison staff and prisoner guidance and first-aid understanding, including failures to recognise the need for CPR or distinguish unconsciousness from 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Careless completion of cell sharing risk assessments
Wider context from the report “1. The completion of the cell sharing risk assessment was described by the extremely experienced nurse who completed it, as careless.
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of seizure-response training for prison staff
Wider context from the report “2. Though I was told that training for prison staff in how to deal with fits is to be given at HMP Pentonville in October 2023 , I heard that there is only a hope that prisoners will also receive some guidance in what to do if their cellmate suffers a fit. Apparently, this has already been implemented in HMP Brixton.
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Unavailability of guidance for prisoners responding to a cellmate’s fit
Wider context from the report “2. Though I was told that training for prison staff in how to deal with fits is to be given at HMP Pentonville in October 2023, I heard that there is only a hope that prisoners will also receive some guidance in what to do if their cellmate suffers a fit . Apparently, this has already been implemented in HMP Brixton.
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of ongoing first aid training for prison officers
Wider context from the report “3. Whilst the fact that not all prison officers receive ongoing first aid training is a national resourcing issue, the level of first aid understanding of some prison officers at HMP Pentonville seemed surprisingly low.
One officer told me that it did not cross his mind to start CPR in the three minutes it took nurses to arrive after Mr Singh was found not breathing. (Mr Singh had been assessed by a custodial manager as having died, but the other officer did not know this at the time.)
A different officer told me he did not know that there is a difference between a person who is unconscious and a person who is dead.
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Low first aid understanding among prison officers
Wider context from the report “3. Whilst the fact that not all prison officers receive ongoing first aid training is a national resourcing issue, the level of first aid understanding of some prison officers at HMP Pentonville seemed surprisingly low .
One officer told me that it did not cross his mind to start CPR in the three minutes it took nurses to arrive after Mr Singh was found not breathing. (Mr Singh had been assessed by a custodial manager as having died, but the other officer did not know this at the time.)
A different officer told me he did not know that there is a difference between a person who is unconscious and a person who is dead .
” Open source report
2 Jul 2021 Mr Khairul Rahman · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 3 Lack of contemporaneous or accurate retrospective documentation of the timing of clinical interactions View source Failure to undertake further observations at intervals guided by the NEWS2 scoring system View source Unclear use of the NEWS2 scoring system and absence of an effective alternative monitoring system 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
Mr Khairul Rahman · 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
Mr Khairul Rahman became unwell during a COVID-19 outbreak at HMP Pentonville, was later admitted to hospital, and died on 22 January 2021 from COVID-19. Concerns included inaccurate or non-contemporaneous documentation of clinical interactions, intervals between observations that did not align with the NEWS2 scoring system, reliance on prisoners to self-report deterioration, and the lack of a clear effective alternative system for monitoring in the prison healthcare setting.
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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of contemporaneous or accurate retrospective documentation of the timing of clinical interactions
Wider context from the report “1. There does not seem to be a robust system in place in the prison healthcare setting for contemporaneous or accurate retrospective documentation of the timing of clinical interactions . I heard evidence and received a further statement, following the conclusion of the inquest, which set out the difficulties that the prison environment causes, in terms of being able to document accurately. However, I remain concerned that the lack of accurate documentation means that subsequent review of the appropriateness of clinical care, in particular, response times is hampered ;
2. The interval to further observations being undertaken were not inline with the NEWS2 scoring system and, in oral evidence, it was set out that prisoners were expected to self-report deterioration. This differs from latter information, provided after the conclusion of the inquest. However, it remains a concern.
The use of the NEWS2 scoring system remains unclear; the post-inquest information seemingly sets out both that this system was only to used after a positive COVID-19 result but also at daily handover.
Whilst recognising that the prison environment differs from a hospital setting, I remain concerned that the care provided was not as guided by the NEWS2 scoring system and that no alternative system appears to be in place that can be used effectively in the prison healthcare setting.
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake further observations at intervals guided by the NEWS2 scoring system
Wider context from the report “1. There does not seem to be a robust system in place in the prison healthcare setting for contemporaneous or accurate retrospective documentation of the timing of clinical interactions. I heard evidence and received a further statement, following the conclusion of the inquest, which set out the difficulties that the prison environment causes, in terms of being able to document accurately. However, I remain concerned that the lack of accurate documentation means that subsequent review of the appropriateness of clinical care, in particular, response times is hampered;
2. The interval to further observations being undertaken were not inline with the NEWS2 scoring system and, in oral evidence, it was set out that prisoners were expected to self-report deterioration . This differs from latter information, provided after the conclusion of the inquest. However, it remains a concern.
The use of the NEWS2 scoring system remains unclear; the post-inquest information seemingly sets out both that this system was only to used after a positive COVID-19 result but also at daily handover.
Whilst recognising that the prison environment differs from a hospital setting, I remain concerned that the care provided was not as guided by the NEWS2 scoring system and that no alternative system appears to be in place that can be used effectively in the prison healthcare setting.
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Unclear use of the NEWS2 scoring system and absence of an effective alternative monitoring system
Wider context from the report “1. There does not seem to be a robust system in place in the prison healthcare setting for contemporaneous or accurate retrospective documentation of the timing of clinical interactions. I heard evidence and received a further statement, following the conclusion of the inquest, which set out the difficulties that the prison environment causes, in terms of being able to document accurately. However, I remain concerned that the lack of accurate documentation means that subsequent review of the appropriateness of clinical care, in particular, response times is hampered;
2. The interval to further observations being undertaken were not inline with the NEWS2 scoring system and, in oral evidence, it was set out that prisoners were expected to self-report deterioration. This differs from latter information, provided after the conclusion of the inquest. However, it remains a concern.
The use of the NEWS2 scoring system remains unclear ; the post-inquest information seemingly sets out both that this system was only to used after a positive COVID-19 result but also at daily handover .
Whilst recognising that the prison environment differs from a hospital setting, I remain concerned that the care provided was not as guided by the NEWS2 scoring system and that no alternative system appears to be in place that can be used effectively in the prison healthcare setting .
” Open source report
30 Oct 2019 Robert Thomas GINN · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 7 Failure to coach non-clinical staff to improve chest compressions View source Failure to check breathing during resuscitation View source Failure of a nurse to administer chest compressions View source Failure to maintain oxygenation throughout nurse-led resuscitation View source Failure to confirm absent breathing using an adequate assessment View source Failure to provide consistently effective chest compressions View source Incorrect application of defibrillator pads View source See 4 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
Robert Thomas GINN · 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
Robert Thomas Ginn hanged himself in his cell at HM Prison Pentonville and was discovered at around 1.05am on 29 November 2018. Concerns were raised about the quality of the nurse-led resuscitation attempt, including failure to check breathing, inadequate oxygenation, variable chest compressions, lack of coaching, and incorrectly applied defibrillator pads.
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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to coach non-clinical staff to improve chest compressions
Wider context from the report “7. No attempt was made by either of the nurses to coach the prison officer to improve the quality of chest compressions .
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to check breathing during resuscitation
Wider context from the report “2. Throughout the resuscitation attempt captured on BWC, no staff member checked Mr Ginn’s breathing .
It is possible that the breathing was checked before the commencement of the bodycam footage, and indeed one of the prison officers said he checked it at the outset, but the footage ran for nearly eleven minutes before the London Ambulance Service arrived and took over, and it was not checked in that time .
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure of a nurse to administer chest compressions
Wider context from the report “8. One of the nurses (Hotel 7) did not administer chest compressions at all . She did not give evidence at inquest and so the reason for this is unclear.
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain oxygenation throughout nurse-led resuscitation
Wider context from the report “4. After the first two minutes of footage, the oxygen mask that had been in place was taken off and no further efforts were made to oxygenate Mr Ginn .
5. Given that Mr Ginn’s heart had stopped beating, he must have stopped breathing as well. A full, effective, nurse led resuscitation attempt should have included an attempt to oxygenate throughout .
Hotel 12 said that she did not do this because Mr Ginn’s jaw was too stiff to insert an airway, but the LAS did so without any difficulty. And if he had been cold and stiff when they arrived, the LAS paramedics would not have commenced resuscitation.
In any event, an oxygen mask can be applied even if there is stiffness (as it was here, but then it was removed two minutes into the resuscitation and nearly nine minutes before LAS took over).
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to confirm absent breathing using an adequate assessment
Wider context from the report “3. At inquest, one of the nurses said that she looked at Mr Ginn’s chest at the outset, but she did not put her cheek to his mouth to listen and feel for breath in order to confirm he was not breathing .
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to provide consistently effective chest compressions
Wider context from the report “6. Chest compressions given by different members of staff were variable and some, including those of one of the nurses, were sub optimal .
At one point, chest compressions were given by a staff member sandwiched between Mr Ginn and the wall, where there was not enough space to be effective .
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Incorrect application of defibrillator pads
Wider context from the report “9. The defibrillator pads were incorrectly applied by the nursing team , rendering the defibrillator reading unreliable .
” Open source report
23 Jan 2019 Tyrone GIVANS · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 8 Failure to maintain single, accurate NOMIS and SystmOne records View source Failure to identify missing historical records and pause later consultations View source Delays in obtaining hearing aids for deaf prisoners View source Danger posed by Spice use in prisons View source Failure to refer prisoners formally to the equalities officer View source Absence of an equalities and disabilities questionnaire on prisoner arrival View source NOMIS failing to support necessary human intervention View source Failure of discipline and healthcare staff to recognise prisoners’ deafness View source See 5 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
Tyrone GIVANS · 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
Tyrone Givans, who was homeless, profoundly deaf and had a history of alcohol and drug use, was remanded into custody at HMP Pentonville after being arrested for assault. The jury concluded that he hanged himself in his cell, although his intentions were unclear. Principal concerns included Spice use in prison, duplicated prison and healthcare records that prevented access to earlier assessments, and inadequate recognition and support of his deafness and disabilities.
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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain single, accurate NOMIS and SystmOne records
Wider context from the report “2. A past spelling error meant that there were two sets of NOMIS prison records for Mr Givans. This meant that there were then two sets of SystmOne healthcare records .
This meant that staff did not have access to records of the assessments conducted before 8 February 2018. However, later consultations were not paused to make enquiries about this. The nature of the IT error was discovered after Mr Givans’ death, but at the time, staff did not seem to recognise the significance of having no earlier records.
Evidence was given that NOMIS in its present form is unsatisfactory and does not lend itself to human intervention. The jury found that the IT system was unfit 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to identify missing historical records and pause later consultations
Wider context from the report “2. A past spelling error meant that there were two sets of NOMIS prison records for Mr Givans. This meant that there were then two sets of SystmOne healthcare records.
This meant that staff did not have access to records of the assessments conducted before 8 February 2018 . However, later consultations were not paused to make enquiries about this . The nature of the IT error was discovered after Mr Givans’ death, but at the time, staff did not seem to recognise the significance of having no earlier records .
Evidence was given that NOMIS in its present form is unsatisfactory and does not lend itself to human intervention. The jury found that the IT system was unfit 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Delays in obtaining hearing aids for deaf prisoners
Wider context from the report “3. Some members of discipline and healthcare staff did not appreciate that Mr Givans was deaf, although others did. He was not formally referred to the prison equalities officer and there was a general lack of awareness of the role of equalities officer.
There was a delay in seeking Mr Givans’ hearing aids and it took two weeks for one to be brought in by a family member . Whilst systems in HMP Pentonville have changed since Mr Givans’ death, such a situation might exist in prisons elsewhere.
There remains no equalities/disabilities questionnaire for completion on prisoners’ arrival to the prison. The first night form could be adapted, but this would be an exercise to be undertaken nationally.
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Danger posed by Spice use in prisons
Wider context from the report “1. Mr Givans’ former cell mate gave evidence that he had seen Mr Givans smoking Spice in their cell on two or three occasions, saying that its use is common within the prison. The jury heard that Spice often makes the user scared and paranoid, and can provoke immediate, extreme and uncharacteristic behaviour.
Drugs are of course a problem in all prisons and dealing with them a great challenge, but Spice poses a particular danger in all sorts of ways, both in Pentonville and across the prison estate.
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to refer prisoners formally to the equalities officer
Wider context from the report “3. Some members of discipline and healthcare staff did not appreciate that Mr Givans was deaf, although others did. He was not formally referred to the prison equalities officer and there was a general lack of awareness of the role of equalities officer .
There was a delay in seeking Mr Givans’ hearing aids and it took two weeks for one to be brought in by a family member. Whilst systems in HMP Pentonville have changed since Mr Givans’ death, such a situation might exist in prisons elsewhere.
There remains no equalities/disabilities questionnaire for completion on prisoners’ arrival to the prison. The first night form could be adapted, but this would be an exercise to be undertaken nationally.
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Absence of an equalities and disabilities questionnaire on prisoner arrival
Wider context from the report “3. Some members of discipline and healthcare staff did not appreciate that Mr Givans was deaf, although others did. He was not formally referred to the prison equalities officer and there was a general lack of awareness of the role of equalities officer.
There was a delay in seeking Mr Givans’ hearing aids and it took two weeks for one to be brought in by a family member. Whilst systems in HMP Pentonville have changed since Mr Givans’ death, such a situation might exist in prisons elsewhere.
There remains no equalities/disabilities questionnaire for completion on prisoners’ arrival to the prison . The first night form could be adapted, but this would be an exercise to be undertaken nationally.
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation NOMIS failing to support necessary human intervention
Wider context from the report “2. A past spelling error meant that there were two sets of NOMIS prison records for Mr Givans. This meant that there were then two sets of SystmOne healthcare records.
This meant that staff did not have access to records of the assessments conducted before 8 February 2018. However, later consultations were not paused to make enquiries about this. The nature of the IT error was discovered after Mr Givans’ death, but at the time, staff did not seem to recognise the significance of having no earlier records.
Evidence was given that NOMIS in its present form is unsatisfactory and does not lend itself to human intervention . The jury found that the IT system was unfit 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure of discipline and healthcare staff to recognise prisoners’ deafness
Wider context from the report “3. Some members of discipline and healthcare staff did not appreciate that Mr Givans was deaf , although others did. He was not formally referred to the prison equalities officer and there was a general lack of awareness of the role of equalities officer.
There was a delay in seeking Mr Givans’ hearing aids and it took two weeks for one to be brought in by a family member. Whilst systems in HMP Pentonville have changed since Mr Givans’ death, such a situation might exist in prisons elsewhere.
There remains no equalities/disabilities questionnaire for completion on prisoners’ arrival to the prison. The first night form could be adapted, but this would be an exercise to be undertaken nationally.
” Open source report
18 Dec 2017 MARK ANTHONY DOYLE · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 9 Lack of clear criteria and defined information for assessing fitness for transfer from F Wing View source Failure to identify and record prisoner-specific trigger factors on ACCT records View source Failure to consider relevant ACCT file material when determining observation frequency View source Lack of process for recording transfer decisions, reasons and decision-maker identity View source Failure to involve prison staff who know the prisoner in ACCT reviews View source Failure to share relevant healthcare information on prisoners’ ACCT records View source Lack of mandatory first aid training for existing prison officers View source Failure to read recent risk-relevant ACCT daily record entries during case reviews View source Poor understanding of when to contact a prisoner’s family during ACCT reviews View source See 6 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
MARK ANTHONY DOYLE · 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
Mark Anthony Doyle was found suspended by a ligature attached to his cell window bars on 21 March 2017 and died in hospital on 28 March 2017 from injuries sustained in the suspension. The inquest identified concerns including errors in recording a significant anniversary on his ACCT, his transfer from F Wing, and a delay in responding to his cell bell. Further concerns related to ACCT review and information-sharing practices, unclear criteria and recording for transfers from F Wing, and the lack of mandatory first-aid training for existing 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of clear criteria and defined information for assessing fitness for transfer from F Wing
Wider context from the report “(3) Decisions that prisoners are fit to be transferred from F Wing are made and conveyed to prison staff by the charge nurse on duty that morning annotating by hand a list of the prisoners on the Wing. There appears to be no clear criteria for assessing when a prisoner is fit for transfer; the information that should be considered in making this determination is left to the discretion of the decision maker ; and there is no process for recording the decision, the reasons for it or the identity of the decision maker in the prisoner’s records or otherwise.
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to identify and record prisoner-specific trigger factors on ACCT records
Wider context from the report “(1) Although recent developments regarding multi-disciplinary involvement in ACCT case reviews and quality assurance ACCT checks are encouraging (as described to me by ████████, Head of Safer Custody), I remain concerned that the following failings were apparent in the ACCT case reviews concerning Mr Doyle conducted on 10 and 20 March 2017, but are not addressed / adequately addressed by the recent initiatives (including the new Weekly Quality Assurance Check):
• Insufficient appreciation of the importance of identifying and recording trigger factors for a particular prisoner on their ACCT inside front cover ;
• Officers undertaking case reviews without reading recent entries on the ACCT daily record relevant to risk;
• Officers determining the frequency of observation levels for an ACCT prisoner without considering relevant material in the ACCT file;
• The ACCT reviewer failing to appreciate the value of involving at least one member of the prison staff who knows the prisoner; and
• Circumstances in which a prisoner’s family could or should be contacted as part of the ACCT review process were poorly understood.
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to consider relevant ACCT file material when determining observation frequency
Wider context from the report “(1) Although recent developments regarding multi-disciplinary involvement in ACCT case reviews and quality assurance ACCT checks are encouraging (as described to me by ████████, Head of Safer Custody), I remain concerned that the following failings were apparent in the ACCT case reviews concerning Mr Doyle conducted on 10 and 20 March 2017, but are not addressed / adequately addressed by the recent initiatives (including the new Weekly Quality Assurance Check):
• Insufficient appreciation of the importance of identifying and recording trigger factors for a particular prisoner on their ACCT inside front cover;
• Officers undertaking case reviews without reading recent entries on the ACCT daily record relevant to risk;
• Officers determining the frequency of observation levels for an ACCT prisoner without considering relevant material in the ACCT file ;
• The ACCT reviewer failing to appreciate the value of involving at least one member of the prison staff who knows the prisoner; and
• Circumstances in which a prisoner’s family could or should be contacted as part of the ACCT review process were poorly understood.
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of process for recording transfer decisions, reasons and decision-maker identity
Wider context from the report “(3) Decisions that prisoners are fit to be transferred from F Wing are made and conveyed to prison staff by the charge nurse on duty that morning annotating by hand a list of the prisoners on the Wing. There appears to be no clear criteria for assessing when a prisoner is fit for transfer; the information that should be considered in making this determination is left to the discretion of the decision maker; and there is no process for recording the decision, the reasons for it or the identity of the decision maker in the prisoner’s records or otherwise .
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to involve prison staff who know the prisoner in ACCT reviews
Wider context from the report “(1) Although recent developments regarding multi-disciplinary involvement in ACCT case reviews and quality assurance ACCT checks are encouraging (as described to me by ████████, Head of Safer Custody), I remain concerned that the following failings were apparent in the ACCT case reviews concerning Mr Doyle conducted on 10 and 20 March 2017, but are not addressed / adequately addressed by the recent initiatives (including the new Weekly Quality Assurance Check):
• Insufficient appreciation of the importance of identifying and recording trigger factors for a particular prisoner on their ACCT inside front cover;
• Officers undertaking case reviews without reading recent entries on the ACCT daily record relevant to risk;
• Officers determining the frequency of observation levels for an ACCT prisoner without considering relevant material in the ACCT file;
• The ACCT reviewer failing to appreciate the value of involving at least one member of the prison staff who knows the prisoner ; and
• Circumstances in which a prisoner’s family could or should be contacted as part of the ACCT review process were poorly understood.
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to share relevant healthcare information on prisoners’ ACCT records
Wider context from the report “(2) Although, ████████, Head of Healthcare, described how healthcare staff have received recent encouragement to make entries on a prisoner’s ACCT in relation to matters that could bear on risk, I am concerned that this does not go far enough to change past practice and ensure that relevant information is shared , in light of the prison staff’s lack of access to System One records and the infrequent occasions that Care UK staff made entries on Mr Doyle’s ACCT daily 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of mandatory first aid training for existing prison officers
Wider context from the report “(4) There is no mandatory first aid training for existing (as opposed to new) prison officers . I was informed that Orderly Officers and OSGs have / are being provided with first aid training, but I am concerned this remains a serious lacuna. I appreciate it is a nationally made resourcing decision and that it has been raised previously, but I raise it for further consideration; in light of the limited number of prison and nursing staff on duty overnight, there is a real prospect of medical emergencies arising where no trained first aider is available .
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to read recent risk-relevant ACCT daily record entries during case reviews
Wider context from the report “(1) Although recent developments regarding multi-disciplinary involvement in ACCT case reviews and quality assurance ACCT checks are encouraging (as described to me by ████████, Head of Safer Custody), I remain concerned that the following failings were apparent in the ACCT case reviews concerning Mr Doyle conducted on 10 and 20 March 2017, but are not addressed / adequately addressed by the recent initiatives (including the new Weekly Quality Assurance Check):
• Insufficient appreciation of the importance of identifying and recording trigger factors for a particular prisoner on their ACCT inside front cover;
• Officers undertaking case reviews without reading recent entries on the ACCT daily record relevant to risk ;
• Officers determining the frequency of observation levels for an ACCT prisoner without considering relevant material in the ACCT file;
• The ACCT reviewer failing to appreciate the value of involving at least one member of the prison staff who knows the prisoner; and
• Circumstances in which a prisoner’s family could or should be contacted as part of the ACCT review process were poorly understood.
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Poor understanding of when to contact a prisoner’s family during ACCT reviews
Wider context from the report “(1) Although recent developments regarding multi-disciplinary involvement in ACCT case reviews and quality assurance ACCT checks are encouraging (as described to me by ████████, Head of Safer Custody), I remain concerned that the following failings were apparent in the ACCT case reviews concerning Mr Doyle conducted on 10 and 20 March 2017, but are not addressed / adequately addressed by the recent initiatives (including the new Weekly Quality Assurance Check):
• Insufficient appreciation of the importance of identifying and recording trigger factors for a particular prisoner on their ACCT inside front cover;
• Officers undertaking case reviews without reading recent entries on the ACCT daily record relevant to risk;
• Officers determining the frequency of observation levels for an ACCT prisoner without considering relevant material in the ACCT file;
• The ACCT reviewer failing to appreciate the value of involving at least one member of the prison staff who knows the prisoner; and
• Circumstances in which a prisoner’s family could or should be contacted as part of the ACCT review process were poorly understood .
” Open source report
31 Oct 2017 Vilhelmas BORKERTAS · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 1 Failure to consider potential dangers in cell-sharing decisions 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
Vilhelmas BORKERTAS · 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
Vilhelmas Borkertas took his own life on 21 November 2016 after his cellmate found him hanging from the window bar. Resuscitation attempts were unsuccessful. The principal concern was that Mr Borkertas, who was described as bisexual, was placed in a cell with a cellmate recorded as homophobic, without evidence that the potential dangers of this were considered; the report stated there was nothing to indicate this affected the outcome but that it might be devastating in another case.
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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to consider potential dangers in cell-sharing decisions
Wider context from the report “Mr Borkertas described himself variously as heterosexual and bisexual. The latter was recorded on his cell sharing risk assessment form. His cellmate at the time of death described himself as being homophobic. This was recorded on his cell sharing risk assessment form. However, the two were placed together in a cell and I heard no evidence that consideration was ever given to the potential dangers of this.
There is nothing to indicate that this had an impact upon the outcome, but it might be devastating in another case.
” Open source report
28 Mar 2017 John WILLIAMS · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 9 Failure to follow up missed second reception screens View source Insufficient training and experience to explore mental health and substance-use issues View source Lack of first aid and CPR training for prison officers View source Failure of prison officers to understand ACCT contents View source Failure of prison officers to understand code blue and code red distinctions View source Failure to accurately record self-harm or suicide assessments View source Failure to make mental health team referrals View source Failure to conduct the second reception screen View source Failure to review and record events in the ACCT document View source See 6 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
John WILLIAMS · 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
John Williams hanged himself while he was a prisoner at HM Prison Pentonville, after telling staff that he would do so if his perceived needs were not met rather than intending to take his life. Concerns included inaccuracies and omissions in reception screening and referrals, inadequate understanding and use of the ACCT document, insufficient training for some support staff, confusion about emergency codes, and a lack of basic first aid and CPR training among 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to follow up missed second reception screens
Wider context from the report “2. There was no second reception screen conducted. If Mr Williams was not brought to healthcare staff for his second reception screen then healthcare staff needed to follow this up .
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Insufficient training and experience to explore mental health and substance-use issues
Wider context from the report “5. Mr Williams also told the member of Phoenix Futures who saw him that he felt cannabis gave him what the mental health team did not. However, the staff member felt he did not have the training or experience to explore either of these issues in greater depth .
It may be that Phoenix Futures staff would benefit from additional training, perhaps alongside prison 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of first aid and CPR training for prison officers
Wider context from the report “7. The prison officers did not have even the most basic first aid and cardiopulmonary resuscitation (CPR) training . I am aware from other inquests that this is not provided at a national level.
I have written about this before. It seems a significant gap, even allowing for the fact that there are always two trained nurses on site.
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure of prison officers to understand ACCT contents
Wider context from the report “4. Mr Williams said to several members of staff that he would self harm or hang himself if he wanted something done and it was not happening quickly enough (rather than because he actually wanted to die.)
This was recorded on his assessment, care in custody, teamwork (ACCT) document. Some prison officers did not seem familiar with the very important contents of the ACCT, not even those inside cover .
The senior officer in charge on the weekend of Mr Williams’ death did not look at the inside cover or record any events within. Again, It appears there may be benefit in additional training and/or supervision.
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure of prison officers to understand code blue and code red distinctions
Wider context from the report “6. The issue of the difference between a code blue and a code red is one about which I have written before.
One senior prison officer said in evidence that if she did not know the difference between a code blue and a code red , then there would be some serious concerns. She did not.
She had been given a small card describing code blue and code red (a card which another officer kept about her person and even produced from the witness box), and she still retained that card. However, she had never considered it worthwhile to read .
She said in court that she still thought it appropriate that she had never read the card.
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to accurately record self-harm or suicide assessments
Wider context from the report “1. The first reception nurse who saw Mr Williams when he entered HMP Pentonville gave evidence that he had no thoughts of self harm or suicide, but she recorded that he had .
It appears she may benefit from additional training and/or supervision.
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to make mental health team referrals
Wider context from the report “3. The first reception nurse did not make the referral to the mental health team (though this took place in any event because the court diversion team had already made the referral).
I heard that it is now done automatically when that box is ticked on the system, and I wonder whether other prison healthcare providers would benefit from such a system.
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct the second reception screen
Wider context from the report “2. There was no second reception screen conducted . If Mr Williams was not brought to healthcare staff for his second reception screen then healthcare staff needed to follow this up.
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to review and record events in the ACCT document
Wider context from the report “4. Mr Williams said to several members of staff that he would self harm or hang himself if he wanted something done and it was not happening quickly enough (rather than because he actually wanted to die.)
This was recorded on his assessment, care in custody, teamwork (ACCT) document. Some prison officers did not seem familiar with the very important contents of the ACCT, not even those inside cover.
The senior officer in charge on the weekend of Mr Williams’ death did not look at the inside cover or record any events within . Again, It appears there may be benefit in additional training and/or supervision.
” Open source report
6 Dec 2016 Tedros Habtom KAHSSAY · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 15 Ineffective chest compressions during CPR View source Failure to assess breathing and perform airway manoeuvres during resuscitation View source Unavailability of a serviceable oxygen cylinder during resuscitation View source Failure of emergency healthcare lead nurses to understand code red and code blue medical emergencies View source Failure to distinguish cardiorespiratory arrest from unconsciousness during emergency assessment View source Delay in providing substantive resuscitation care after nurse arrival View source Failure to explore recorded history of depression during reception screening View source Failure to record circumstances of the index offence in the healthcare record View source Failure to obtain general practitioner records View source Failure to apply objective clinical analysis during nurse reception screening View source Failure to check pulse during resuscitation View source Insufficient airway ventilation assistance during resuscitation View source Failure to maintain clear resuscitation roles and responsibilities View source Ambiguity in reception screening questions for identifying increased-risk prisoners View source Failure to transfer person escort and forensic medical records to nurse reception screening View source See 12 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
Tedros Habtom KAHSSAY · 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
Tedros Kahssay killed himself by hanging in HM Prison Pentonville about a month after being admitted on a charge of murdering his pregnant partner. Concerns included incomplete transfer and recording of information, shortcomings in reception screening, and significantly deficient and chaotic resuscitation procedures. The report states that he was already dead when resuscitation commenced, while expressing concern for other prisoners requiring first aid.
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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Ineffective chest compressions during CPR
Wider context from the report “7. The resuscitation led by the two nurses occupying the positions of primary (Hotel 7) and secondary (Hotel 12) leads for emergency healthcare in the prison that night, was significantly lacking in the following ways.
• The nurse with primary responsibility for emergency care in the prison did not have a proper understanding of the nature of a code red and a code blue prison medical emergency. (I have raised this issue in the past.)
• One minute and twelve seconds elapsed after nurse arrival before any substantive care was given. The action during that one minute and twelve seconds did not appear to progress the resuscitation attempt.
• There seemed no clear demarcation of roles and responsibilities during the resuscitation. Of course these may change as those giving resuscitation tire, but the changes seemed haphazard.
• There was no checking for breath or airway manoeuvre at the outset or at any time during the resuscitation.
• There was no checking for pulse at the outset, before commencing chest compressions, or at any time during the resuscitation.
The lead nurse attempted to justify this by saying that she had not wanted to waste time. This was despite the first action upon finding the casualty being to apply a blood pressure cuff, on the basis that this was part of the nurse assessment.
• When giving evidence, the lead nurse appeared to conflate the casualty who is in cardiorespiratory arrest with the casualty who is merely unconscious. She repeatedly talked about the need to give cardiopulmonary resuscitation (CPR) to an unconscious casualty. She said that, at the time she started chest compressions, she did not know whether Mr Kahssay was breathing or not breathing.
• When CPR was given, chest compressions were ineffective, being too quick and too shallow .
• There was only one brief attempt to use an ambubag, the majority of the resuscitation taking place without airway assistance or with a non rebreathe oxygen mask.
• It appeared that one oxygen cylinder was empty, as it had to be changed for another.
The nurse leading the resuscitation described it as chaotic. That is indeed how it appeared to me from her description and from viewing the bodycam footage.
I was and remain very gravely concerned, not in this respect for Mr Kahssay who was in fact already dead when resuscitation commenced, but for anyone else in the prison in need of first aid.
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to assess breathing and perform airway manoeuvres during resuscitation
Wider context from the report “7. The resuscitation led by the two nurses occupying the positions of primary (Hotel 7) and secondary (Hotel 12) leads for emergency healthcare in the prison that night, was significantly lacking in the following ways.
• The nurse with primary responsibility for emergency care in the prison did not have a proper understanding of the nature of a code red and a code blue prison medical emergency. (I have raised this issue in the past.)
• One minute and twelve seconds elapsed after nurse arrival before any substantive care was given. The action during that one minute and twelve seconds did not appear to progress the resuscitation attempt.
• There seemed no clear demarcation of roles and responsibilities during the resuscitation. Of course these may change as those giving resuscitation tire, but the changes seemed haphazard.
• There was no checking for breath or airway manoeuvre at the outset or at any time during the resuscitation .
• There was no checking for pulse at the outset, before commencing chest compressions, or at any time during the resuscitation.
The lead nurse attempted to justify this by saying that she had not wanted to waste time. This was despite the first action upon finding the casualty being to apply a blood pressure cuff, on the basis that this was part of the nurse assessment.
• When giving evidence, the lead nurse appeared to conflate the casualty who is in cardiorespiratory arrest with the casualty who is merely unconscious. She repeatedly talked about the need to give cardiopulmonary resuscitation (CPR) to an unconscious casualty. She said that, at the time she started chest compressions, she did not know whether Mr Kahssay was breathing or not breathing.
• When CPR was given, chest compressions were ineffective, being too quick and too shallow.
• There was only one brief attempt to use an ambubag, the majority of the resuscitation taking place without airway assistance or with a non rebreathe oxygen mask.
• It appeared that one oxygen cylinder was empty, as it had to be changed for another.
The nurse leading the resuscitation described it as chaotic. That is indeed how it appeared to me from her description and from viewing the bodycam footage.
I was and remain very gravely concerned, not in this respect for Mr Kahssay who was in fact already dead when resuscitation commenced, but for anyone else in the prison in need of first aid.
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Unavailability of a serviceable oxygen cylinder during resuscitation
Wider context from the report “7. The resuscitation led by the two nurses occupying the positions of primary (Hotel 7) and secondary (Hotel 12) leads for emergency healthcare in the prison that night, was significantly lacking in the following ways.
• The nurse with primary responsibility for emergency care in the prison did not have a proper understanding of the nature of a code red and a code blue prison medical emergency. (I have raised this issue in the past.)
• One minute and twelve seconds elapsed after nurse arrival before any substantive care was given. The action during that one minute and twelve seconds did not appear to progress the resuscitation attempt.
• There seemed no clear demarcation of roles and responsibilities during the resuscitation. Of course these may change as those giving resuscitation tire, but the changes seemed haphazard.
• There was no checking for breath or airway manoeuvre at the outset or at any time during the resuscitation.
• There was no checking for pulse at the outset, before commencing chest compressions, or at any time during the resuscitation.
The lead nurse attempted to justify this by saying that she had not wanted to waste time. This was despite the first action upon finding the casualty being to apply a blood pressure cuff, on the basis that this was part of the nurse assessment.
• When giving evidence, the lead nurse appeared to conflate the casualty who is in cardiorespiratory arrest with the casualty who is merely unconscious. She repeatedly talked about the need to give cardiopulmonary resuscitation (CPR) to an unconscious casualty. She said that, at the time she started chest compressions, she did not know whether Mr Kahssay was breathing or not breathing.
• When CPR was given, chest compressions were ineffective, being too quick and too shallow.
• There was only one brief attempt to use an ambubag, the majority of the resuscitation taking place without airway assistance or with a non rebreathe oxygen mask.
• It appeared that one oxygen cylinder was empty , as it had to be changed for another .
The nurse leading the resuscitation described it as chaotic. That is indeed how it appeared to me from her description and from viewing the bodycam footage.
I was and remain very gravely concerned, not in this respect for Mr Kahssay who was in fact already dead when resuscitation commenced, but for anyone else in the prison in need of first aid.
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure of emergency healthcare lead nurses to understand code red and code blue medical emergencies
Wider context from the report “7. The resuscitation led by the two nurses occupying the positions of primary (Hotel 7) and secondary (Hotel 12) leads for emergency healthcare in the prison that night, was significantly lacking in the following ways.
• The nurse with primary responsibility for emergency care in the prison did not have a proper understanding of the nature of a code red and a code blue prison medical emergency . (I have raised this issue in the past.)
• One minute and twelve seconds elapsed after nurse arrival before any substantive care was given. The action during that one minute and twelve seconds did not appear to progress the resuscitation attempt.
• There seemed no clear demarcation of roles and responsibilities during the resuscitation. Of course these may change as those giving resuscitation tire, but the changes seemed haphazard.
• There was no checking for breath or airway manoeuvre at the outset or at any time during the resuscitation.
• There was no checking for pulse at the outset, before commencing chest compressions, or at any time during the resuscitation.
The lead nurse attempted to justify this by saying that she had not wanted to waste time. This was despite the first action upon finding the casualty being to apply a blood pressure cuff, on the basis that this was part of the nurse assessment.
• When giving evidence, the lead nurse appeared to conflate the casualty who is in cardiorespiratory arrest with the casualty who is merely unconscious. She repeatedly talked about the need to give cardiopulmonary resuscitation (CPR) to an unconscious casualty. She said that, at the time she started chest compressions, she did not know whether Mr Kahssay was breathing or not breathing.
• When CPR was given, chest compressions were ineffective, being too quick and too shallow.
• There was only one brief attempt to use an ambubag, the majority of the resuscitation taking place without airway assistance or with a non rebreathe oxygen mask.
• It appeared that one oxygen cylinder was empty, as it had to be changed for another.
The nurse leading the resuscitation described it as chaotic. That is indeed how it appeared to me from her description and from viewing the bodycam footage.
I was and remain very gravely concerned, not in this respect for Mr Kahssay who was in fact already dead when resuscitation commenced, but for anyone else in the prison in need of first aid.
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to distinguish cardiorespiratory arrest from unconsciousness during emergency assessment
Wider context from the report “7. The resuscitation led by the two nurses occupying the positions of primary (Hotel 7) and secondary (Hotel 12) leads for emergency healthcare in the prison that night, was significantly lacking in the following ways.
• The nurse with primary responsibility for emergency care in the prison did not have a proper understanding of the nature of a code red and a code blue prison medical emergency. (I have raised this issue in the past.)
• One minute and twelve seconds elapsed after nurse arrival before any substantive care was given. The action during that one minute and twelve seconds did not appear to progress the resuscitation attempt.
• There seemed no clear demarcation of roles and responsibilities during the resuscitation. Of course these may change as those giving resuscitation tire, but the changes seemed haphazard.
• There was no checking for breath or airway manoeuvre at the outset or at any time during the resuscitation.
• There was no checking for pulse at the outset, before commencing chest compressions, or at any time during the resuscitation.
The lead nurse attempted to justify this by saying that she had not wanted to waste time. This was despite the first action upon finding the casualty being to apply a blood pressure cuff, on the basis that this was part of the nurse assessment.
• When giving evidence, the lead nurse appeared to conflate the casualty who is in cardiorespiratory arrest with the casualty who is merely unconscious . She repeatedly talked about the need to give cardiopulmonary resuscitation (CPR) to an unconscious casualty. She said that, at the time she started chest compressions, she did not know whether Mr Kahssay was breathing or not breathing .
• When CPR was given, chest compressions were ineffective, being too quick and too shallow.
• There was only one brief attempt to use an ambubag, the majority of the resuscitation taking place without airway assistance or with a non rebreathe oxygen mask.
• It appeared that one oxygen cylinder was empty, as it had to be changed for another.
The nurse leading the resuscitation described it as chaotic. That is indeed how it appeared to me from her description and from viewing the bodycam footage.
I was and remain very gravely concerned, not in this respect for Mr Kahssay who was in fact already dead when resuscitation commenced, but for anyone else in the prison in need of first aid.
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Delay in providing substantive resuscitation care after nurse arrival
Wider context from the report “7. The resuscitation led by the two nurses occupying the positions of primary (Hotel 7) and secondary (Hotel 12) leads for emergency healthcare in the prison that night, was significantly lacking in the following ways.
• The nurse with primary responsibility for emergency care in the prison did not have a proper understanding of the nature of a code red and a code blue prison medical emergency. (I have raised this issue in the past.)
• One minute and twelve seconds elapsed after nurse arrival before any substantive care was given . The action during that one minute and twelve seconds did not appear to progress the resuscitation attempt .
• There seemed no clear demarcation of roles and responsibilities during the resuscitation. Of course these may change as those giving resuscitation tire, but the changes seemed haphazard.
• There was no checking for breath or airway manoeuvre at the outset or at any time during the resuscitation.
• There was no checking for pulse at the outset, before commencing chest compressions, or at any time during the resuscitation.
The lead nurse attempted to justify this by saying that she had not wanted to waste time. This was despite the first action upon finding the casualty being to apply a blood pressure cuff, on the basis that this was part of the nurse assessment.
• When giving evidence, the lead nurse appeared to conflate the casualty who is in cardiorespiratory arrest with the casualty who is merely unconscious. She repeatedly talked about the need to give cardiopulmonary resuscitation (CPR) to an unconscious casualty. She said that, at the time she started chest compressions, she did not know whether Mr Kahssay was breathing or not breathing.
• When CPR was given, chest compressions were ineffective, being too quick and too shallow.
• There was only one brief attempt to use an ambubag, the majority of the resuscitation taking place without airway assistance or with a non rebreathe oxygen mask.
• It appeared that one oxygen cylinder was empty, as it had to be changed for another.
The nurse leading the resuscitation described it as chaotic. That is indeed how it appeared to me from her description and from viewing the bodycam footage.
I was and remain very gravely concerned, not in this respect for Mr Kahssay who was in fact already dead when resuscitation commenced, but for anyone else in the prison in need of first aid.
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to explore recorded history of depression during reception screening
Wider context from the report “6. The second reception (well man) screening nurse did not explore the history of depression recorded , he said because the prison general practitioner had not prescribed any medication for depression. On reflection, the nurse thought that he should have asked about it.
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to record circumstances of the index offence in the healthcare record
Wider context from the report “2. The index offence is recorded on the PER (and inputted onto the prison computer system NOMIS, though not the healthcare computer system SystmOne ), but not the circumstances . The circumstances – perhaps from the indictment read out in court – may be potentially helpful to healthcare and possibly also to discipline staff in prison.
This is not clear cut, because the logistics of obtaining the information and making it available to those who need it are complex; prosecutions must not be compromised; and there is the potential for making a prisoner’s mental state worse by probing the circumstances.
However, it seems that this is an issue that is worthy of consideration, preferably at a national level.
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain general practitioner records
Wider context from the report “3. The general practitioner records were never obtained (an issue that I have raised in the past), despite there being a system in place for Pentonville healthcare administrative staff to do this. Whilst that did not impact upon Mr Kahssay’s care, it might for another prisoner.
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to apply objective clinical analysis during nurse reception screening
Wider context from the report “5. Both nurses conducting reception screening talked often in evidence about not being able to do anything other than accept the answers given by the prisoner. They did not seem to bring any objective analysis to the screening . The process of nurse screening appeared at times to be a tick box exercise .
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to check pulse during resuscitation
Wider context from the report “7. The resuscitation led by the two nurses occupying the positions of primary (Hotel 7) and secondary (Hotel 12) leads for emergency healthcare in the prison that night, was significantly lacking in the following ways.
• The nurse with primary responsibility for emergency care in the prison did not have a proper understanding of the nature of a code red and a code blue prison medical emergency. (I have raised this issue in the past.)
• One minute and twelve seconds elapsed after nurse arrival before any substantive care was given. The action during that one minute and twelve seconds did not appear to progress the resuscitation attempt.
• There seemed no clear demarcation of roles and responsibilities during the resuscitation. Of course these may change as those giving resuscitation tire, but the changes seemed haphazard.
• There was no checking for breath or airway manoeuvre at the outset or at any time during the resuscitation.
• There was no checking for pulse at the outset, before commencing chest compressions, or at any time during the resuscitation .
The lead nurse attempted to justify this by saying that she had not wanted to waste time. This was despite the first action upon finding the casualty being to apply a blood pressure cuff, on the basis that this was part of the nurse assessment.
• When giving evidence, the lead nurse appeared to conflate the casualty who is in cardiorespiratory arrest with the casualty who is merely unconscious. She repeatedly talked about the need to give cardiopulmonary resuscitation (CPR) to an unconscious casualty. She said that, at the time she started chest compressions, she did not know whether Mr Kahssay was breathing or not breathing.
• When CPR was given, chest compressions were ineffective, being too quick and too shallow.
• There was only one brief attempt to use an ambubag, the majority of the resuscitation taking place without airway assistance or with a non rebreathe oxygen mask.
• It appeared that one oxygen cylinder was empty, as it had to be changed for another.
The nurse leading the resuscitation described it as chaotic. That is indeed how it appeared to me from her description and from viewing the bodycam footage.
I was and remain very gravely concerned, not in this respect for Mr Kahssay who was in fact already dead when resuscitation commenced, but for anyone else in the prison in need of first aid.
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Insufficient airway ventilation assistance during resuscitation
Wider context from the report “7. The resuscitation led by the two nurses occupying the positions of primary (Hotel 7) and secondary (Hotel 12) leads for emergency healthcare in the prison that night, was significantly lacking in the following ways.
• The nurse with primary responsibility for emergency care in the prison did not have a proper understanding of the nature of a code red and a code blue prison medical emergency. (I have raised this issue in the past.)
• One minute and twelve seconds elapsed after nurse arrival before any substantive care was given. The action during that one minute and twelve seconds did not appear to progress the resuscitation attempt.
• There seemed no clear demarcation of roles and responsibilities during the resuscitation. Of course these may change as those giving resuscitation tire, but the changes seemed haphazard.
• There was no checking for breath or airway manoeuvre at the outset or at any time during the resuscitation.
• There was no checking for pulse at the outset, before commencing chest compressions, or at any time during the resuscitation.
The lead nurse attempted to justify this by saying that she had not wanted to waste time. This was despite the first action upon finding the casualty being to apply a blood pressure cuff, on the basis that this was part of the nurse assessment.
• When giving evidence, the lead nurse appeared to conflate the casualty who is in cardiorespiratory arrest with the casualty who is merely unconscious. She repeatedly talked about the need to give cardiopulmonary resuscitation (CPR) to an unconscious casualty. She said that, at the time she started chest compressions, she did not know whether Mr Kahssay was breathing or not breathing.
• When CPR was given, chest compressions were ineffective, being too quick and too shallow.
• There was only one brief attempt to use an ambubag , the majority of the resuscitation taking place without airway assistance or with a non rebreathe oxygen mask .
• It appeared that one oxygen cylinder was empty, as it had to be changed for another.
The nurse leading the resuscitation described it as chaotic. That is indeed how it appeared to me from her description and from viewing the bodycam footage.
I was and remain very gravely concerned, not in this respect for Mr Kahssay who was in fact already dead when resuscitation commenced, but for anyone else in the prison in need of first aid.
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain clear resuscitation roles and responsibilities
Wider context from the report “7. The resuscitation led by the two nurses occupying the positions of primary (Hotel 7) and secondary (Hotel 12) leads for emergency healthcare in the prison that night, was significantly lacking in the following ways.
• The nurse with primary responsibility for emergency care in the prison did not have a proper understanding of the nature of a code red and a code blue prison medical emergency. (I have raised this issue in the past.)
• One minute and twelve seconds elapsed after nurse arrival before any substantive care was given. The action during that one minute and twelve seconds did not appear to progress the resuscitation attempt.
• There seemed no clear demarcation of roles and responsibilities during the resuscitation . Of course these may change as those giving resuscitation tire, but the changes seemed haphazard .
• There was no checking for breath or airway manoeuvre at the outset or at any time during the resuscitation.
• There was no checking for pulse at the outset, before commencing chest compressions, or at any time during the resuscitation.
The lead nurse attempted to justify this by saying that she had not wanted to waste time. This was despite the first action upon finding the casualty being to apply a blood pressure cuff, on the basis that this was part of the nurse assessment.
• When giving evidence, the lead nurse appeared to conflate the casualty who is in cardiorespiratory arrest with the casualty who is merely unconscious. She repeatedly talked about the need to give cardiopulmonary resuscitation (CPR) to an unconscious casualty. She said that, at the time she started chest compressions, she did not know whether Mr Kahssay was breathing or not breathing.
• When CPR was given, chest compressions were ineffective, being too quick and too shallow.
• There was only one brief attempt to use an ambubag, the majority of the resuscitation taking place without airway assistance or with a non rebreathe oxygen mask.
• It appeared that one oxygen cylinder was empty, as it had to be changed for another.
The nurse leading the resuscitation described it as chaotic. That is indeed how it appeared to me from her description and from viewing the bodycam footage.
I was and remain very gravely concerned, not in this respect for Mr Kahssay who was in fact already dead when resuscitation commenced, but for anyone else in the prison in need of first aid.
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Ambiguity in reception screening questions for identifying increased-risk prisoners
Wider context from the report “4. The first reception screen template contained questions that carried an inherent ambiguity , in that they related to a change in personal and family circumstances, which must always be the case when a person is incarcerated and therefore does not assist in determining which prisoners are at an increased risk .
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to transfer person escort and forensic medical records to nurse reception screening
Wider context from the report “1. The person escort record (PER) and appended report of the forensic medical examiner (FME) that accompanied Mr Kahssay to HMP Pentonville did not accompany him to nurse reception screening .
” Open source report
26 Jul 2016 Terence Darren ADAMS · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 9 Delays and failures in disclosing root cause analyses to the coroner View source Failure to explore potential triggers for disclosed suicidal thoughts View source Unavailability of the first night reception template key to the assessing GP View source Failure of the assessing GP to recognise the inpatient healthcare threshold in the first night reception template View source Failure to follow up non-attendance at the second reception screen View source Failure to share root cause analyses with relevant internal safety and healthcare leaders View source Failure to check prison escort records for required attachments View source Failure to ensure staff understand the status of the first night reception template View source Failure of the first night reception template to indicate that its instructions are advisory rather than mandatory View source See 6 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
Terence Darren ADAMS · 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
Terence Darren Adams committed suicide by hanging himself in his cell at HM Prison Pentonville. Concerns included failures in checking prison escort records, understanding and acting on the first night reception template, exploring his suicidal history, ensuring attendance at a follow-up reception screen, and sharing the root cause analysis needed for learning lessons.
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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Delays and failures in disclosing root cause analyses to the coroner
Wider context from the report “6. The root cause analysis (RCA) conducted by Care UK after Mr Adams’ death in November 2015, and finalised in February 2016, was not shared with HM Coroner until part way through the inquest , and then only following the accidental discovery of its existence by two of the inquest advocates. It had not been shared with HMP Pentonville’s head of safer custody governor; nor even with the deputy head of healthcare of Care UK itself. Its existence had not been disclosed to HM Coroner .
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to explore potential triggers for disclosed suicidal thoughts
Wider context from the report “4. Mr Adams told the GP that he had been suicidal on and off for twenty years, but she did not explore with him the potential triggers for this . In fact, one such trigger was incarceration.
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Unavailability of the first night reception template key to the assessing GP
Wider context from the report “2. The general practitioner (GP) who saw Mr Adams when he first arrived at HMP Pentonville did not have the key for the first night reception template when she considered the information contained therein. Mr Adams scored 8. The GP did not know that the advice on the template for scores of 6 and over was to admit the prisoner to inpatient healthcare.
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure of the assessing GP to recognise the inpatient healthcare threshold in the first night reception template
Wider context from the report “2. The general practitioner (GP) who saw Mr Adams when he first arrived at HMP Pentonville did not have the key for the first night reception template when she considered the information contained therein. Mr Adams scored 8. The GP did not know that the advice on the template for scores of 6 and over was to admit the prisoner to inpatient healthcare .
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to follow up non-attendance at the second reception screen
Wider context from the report “5. On the morning he died, Mr Adams should have attended his second reception screen, also known as the well man clinic. When he did not arrive, the healthcare nurse did not attempt to find out why or to secure his attendance .
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to share root cause analyses with relevant internal safety and healthcare leaders
Wider context from the report “6. The root cause analysis (RCA) conducted by Care UK after Mr Adams’ death in November 2015, and finalised in February 2016, was not shared with HM Coroner until part way through the inquest, and then only following the accidental discovery of its existence by two of the inquest advocates. It had not been shared with HMP Pentonville’s head of safer custody governor; nor even with the deputy head of healthcare of Care UK itself . Its existence had not been disclosed to HM Coroner.
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to check prison escort records for required attachments
Wider context from the report “1. I heard at inquest that the prison escort record (PER) that accompanies each prisoner to HMP Pentonville (and which in the future will be forwarded to healthcare staff), is not checked on arrival and thereafter to ensure that, as it progresses through the prison, it includes the attachments described within the document , for example the risk assessment conducted by the police. This seems an unhelpful omission.
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure staff understand the status of the first night reception template
Wider context from the report “3. Neither the nurse nor the GP conducting the first night reception interviews was clear about the status of the first night reception template . The nurse, particularly, talked about it being a document referring to historical matters, whereas the reality is that it encompasses both past and relevant current issues. The document did not give any indication on the face of it that its instructions are advisory rather than mandatory.
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure of the first night reception template to indicate that its instructions are advisory rather than mandatory
Wider context from the report “3. Neither the nurse nor the GP conducting the first night reception interviews was clear about the status of the first night reception template. The nurse, particularly, talked about it being a document referring to historical matters, whereas the reality is that it encompasses both past and relevant current issues. The document did not give any indication on the face of it that its instructions are advisory rather than mandatory .
” Open source report
19 May 2016 Samuel Rodney Darren BLAIR · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 16 Failure to refer antidepressant history to a prison GP View source Failure to enter collateral history into the main clinical records View source Failure to record assessment of mood and suicidal thoughts during prison triage View source Failure to assess drug use during prison triage View source Failure to consider continuation of prescribed citalopram View source Failure to record consideration or a management plan for depression View source Delay in providing the ambulance with the prison gate location View source Inconsistent understanding of prison healthcare emergency procedures View source Out-of-date intermediate life support certification View source Delay in emergency nurse attendance at the patient’s side View source Failure to record discussion or a management plan for schizophrenia View source Failure to recognise prior compliant antidepressant treatment View source Restricted immediate access to the emergency defibrillator View source Failure to promptly acknowledge emergency radio calls View source Lack of current mandatory basic life support and first aid training for all prison officers View source Failure to re-check the pulse during resuscitation View source See 13 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Samuel Rodney Darren BLAIR · 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
Rodney Blair, who had a history of paranoid schizophrenia, alcohol dependency, multiple drug use and depression, was remanded in custody at HM Prison Pentonville and was found hanging in his cell on 2 August 2015. The inquest concluded that his death was suicide, with several contributing factors. Concerns included gaps in assessment and management of his mental health and antidepressant treatment, and delays and procedural issues in the prison emergency response.
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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to refer antidepressant history to a prison GP
Wider context from the report “4. There is no record from that meeting or any other time, of any consideration of or management plan for Mr Blair’s depression.
Most particularly, there is no record that it was ever recognised by the healthcare staff at HMP Pentonville that Mr Blair had been prescribed and had been compliant with the prescription of an anti depressant before his incarceration.
The assistant psychologist who obtained the history of a prescription of anti depressant medication did not refer Mr Blair to a prison GP for consideration of this .
Mr Blair was never offered any continuation of his citalopram prescription. The plan in the community had been to continue the prescription, but there is no record that this was ever considered by healthcare staff at HMP Pentonville.
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to enter collateral history into the main clinical records
Wider context from the report “2. She later uploaded to the computer system the collateral history she had been sent as a Word document, but did not input any of it into the main body of the records , nor did the psychiatrist who made the note at the multi disciplinary team meeting in prison on 7 July 2015 at which Mr Blair was discussed.
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to record assessment of mood and suicidal thoughts during prison triage
Wider context from the report “1. Although the assistant psychologist who triaged Mr Blair in prison on 2 July 2015 asked him about his alcohol dependency, she did not ask him about drug use, nor did she record asking him about his mood or any suicidal thoughts.
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to assess drug use during prison triage
Wider context from the report “1. Although the assistant psychologist who triaged Mr Blair in prison on 2 July 2015 asked him about his alcohol dependency, she did not ask him about drug use , nor did she record asking him about his mood or any suicidal thoughts.
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to consider continuation of prescribed citalopram
Wider context from the report “4. There is no record from that meeting or any other time, of any consideration of or management plan for Mr Blair’s depression.
Most particularly, there is no record that it was ever recognised by the healthcare staff at HMP Pentonville that Mr Blair had been prescribed and had been compliant with the prescription of an anti depressant before his incarceration.
The assistant psychologist who obtained the history of a prescription of anti depressant medication did not refer Mr Blair to a prison GP for consideration of this.
Mr Blair was never offered any continuation of his citalopram prescription . The plan in the community had been to continue the prescription, but there is no record that this was ever considered by healthcare staff at HMP Pentonville .
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to record consideration or a management plan for depression
Wider context from the report “4. There is no record from that meeting or any other time, of any consideration of or management plan for Mr Blair’s depression .
Most particularly, there is no record that it was ever recognised by the healthcare staff at HMP Pentonville that Mr Blair had been prescribed and had been compliant with the prescription of an anti depressant before his incarceration.
The assistant psychologist who obtained the history of a prescription of anti depressant medication did not refer Mr Blair to a prison GP for consideration of this.
Mr Blair was never offered any continuation of his citalopram prescription. The plan in the community had been to continue the prescription, but there is no record that this was ever considered by healthcare staff at HMP Pentonville.
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Delay in providing the ambulance with the prison gate location
Wider context from the report “5. After Mr Blair was found hanging, the officer in the prison control room did not give the prison gate location for the ambulance at the very outset of the 999 call to London Ambulance Service, but instead did so part way through the call.
The LAS controller did not ask at the very outset.
The ideal would be for the information to be given at the very beginning of any emergency call .
(I wrote to HMP Pentonville on 16 September 2016 in connection with the death of another prisoner about this issue. I appreciate that work on this matter is ongoing.)
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Inconsistent understanding of prison healthcare emergency procedures
Wider context from the report “9. That nurse gave a description of the code blue and code red system of describing an emergency, that was markedly different from the understanding given by the prison governor and the London Ambulance Service . I heard that the codes blue and red are even described on posters within the prison.
It therefore appears that a nurse within the prison healthcare team has the wrong understanding of basic prison healthcare emergency procedures .
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Out-of-date intermediate life support certification
Wider context from the report “8. That nurse (a mental health, rather than general nurse) began resuscitation. He gave evidence that he started chest compressions and continued these for two minutes until a custodial manager arrived, without any intention of ever stopping to re-check Mr Blair’s pulse.
He said that, whilst his basic life support certification was current at the time of Mr Blair’s death, his intermediate life support certification was not, and is still not ; it is currently at least three years out of date .
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Delay in emergency nurse attendance at the patient’s side
Wider context from the report “6. The prison nurse on call for emergencies, call sign Hotel 7, who was called to attend Mr Blair after he had been found hanging, did not acknowledge the radio call for several minutes, despite numerous attempts by prison control.
When she finally did acknowledge the emergency, there was a delay of up to approximately 15 minutes before she was at Mr Blair’s side .
(I wrote to HMP Pentonville on 16 September 2016 in connection with the death of another prisoner about a different nurse, but also in the role of Hotel 7, who did not respond to an emergency alarm as soon as it was activated.)
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to record discussion or a management plan for schizophrenia
Wider context from the report “3. There is no record from that meeting of any discussion or management plan for Mr Blair’s schizophrenia .
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise prior compliant antidepressant treatment
Wider context from the report “4. There is no record from that meeting or any other time, of any consideration of or management plan for Mr Blair’s depression.
Most particularly, there is no record that it was ever recognised by the healthcare staff at HMP Pentonville that Mr Blair had been prescribed and had been compliant with the prescription of an anti depressant before his incarceration .
The assistant psychologist who obtained the history of a prescription of anti depressant medication did not refer Mr Blair to a prison GP for consideration of this.
Mr Blair was never offered any continuation of his citalopram prescription. The plan in the community had been to continue the prescription, but there is no record that this was ever considered by healthcare staff at HMP Pentonville.
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Restricted immediate access to the emergency defibrillator
Wider context from the report “7. The substance misuse nurse in the detoxification wing did respond immediately. He took his emergency bag with him to Mr Blair’s cell, but did not take the defibrillator stored in the same room as the bag . He later had to leave Mr Blair to retrieve the defibrillator , because it is stored in the nurses’ room and only nurses have the key .
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to promptly acknowledge emergency radio calls
Wider context from the report “6. The prison nurse on call for emergencies, call sign Hotel 7, who was called to attend Mr Blair after he had been found hanging, did not acknowledge the radio call for several minutes, despite numerous attempts by prison control .
When she finally did acknowledge the emergency, there was a delay of up to approximately 15 minutes before she was at Mr Blair’s side.
(I wrote to HMP Pentonville on 16 September 2016 in connection with the death of another prisoner about a different nurse, but also in the role of Hotel 7, who did not respond to an emergency alarm as soon as it was activated.)
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of current mandatory basic life support and first aid training for all prison officers
Wider context from the report “The prison officers who found Mr Blair hanging did not have current basic life support training and so were not able to commence cardiopulmonary resuscitation (CPR) before the arrival of nurses . One officer tried to take Mr Blair’s pulse, but was unclear about the correct procedure for this .
This is a situation that I have noted before at HMP Pentonville. I have not made a prevention of future deaths report in the past, because I am aware that the fact that there is no mandatory first aid (including CPR) training for all prison officers is a nationally made, resource led decision.
However, it seems to me that you, as the decision maker regarding not providing such training, should be aware of the impact that this may have on the prison population.
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to re-check the pulse during resuscitation
Wider context from the report “8. That nurse (a mental health, rather than general nurse) began resuscitation. He gave evidence that he started chest compressions and continued these for two minutes until a custodial manager arrived, without any intention of ever stopping to re-check Mr Blair’s pulse .
He said that, whilst his basic life support certification was current at the time of Mr Blair’s death, his intermediate life support certification was not, and is still not; it is currently at least three years out of date.
” 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 Continue working with the healthcare provider to ensure staff understand the steps required when responding to emergency calls.
Verbatim wording from the response “This report also brings to the attention of the Governor the inadequate response of a nurse to the emergency call from the control room. As you point out in your report, the local protocol on action to be taken in response to emergency response codes is well publicised throughout the prison. The prison will continue to work with the healthcare provider to ensure that all staff are aware of the steps that they are required to take when responding to an emergency call.” Source location 2016-0196-Response-by-NOMS
Open published response
×
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 Ensure sufficient suitably trained first aiders are available through establishment first-aid risk assessments and current competency certification.
Verbatim wording from the response “The report that you addressed to NOMS expresses concern that the staff who discovered Mr Blair had not received cardiopulmonary resuscitation (CPR) training. It correctly states that the NOMS position is that such training is not mandatory for all prison staff. However, it is not correct to characterise this as a ‘resource-led’ decision. NOMS is committed to ensuring that a sufficient number of suitably trained first aiders is always available in prisons to enable First Aid to be given to employees, prisoners and visitors. Prison Service Instruction 29/2015 First Aid, issued on 16 November 2015, requires every establishment to carry out a First Aid risk assessment to identify the number of trained first aiders required to provide cover throughout the day.” Source location 2016-0196-Response-by-NOMS
Open published response
×
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 Require prison control rooms to provide the gate location at the beginning of ambulance calls and brief staff on the requirement.
Verbatim wording from the response “The separate report addressed to the Governor raises concern about the fact that the prison’s control room did not immediately provide the London Ambulance Service (LAS) with the gate location when they requested the attendance of an ambulance. I can confirm that since Mr Blair’s death, colleagues at Pentonville have met the LAS to discuss this issue, and it has been agreed that the prison gate location will be” Source location 2016-0196-Response-by-NOMS
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 risk-assessed first-aid staffing and 24-hour healthcare cover were considered sufficient, so CPR training was not mandatory for all prison staff.
Verbatim wording from the response “The report that you addressed to NOMS expresses concern that the staff who discovered Mr Blair had not received cardiopulmonary resuscitation (CPR) training. It correctly states that the NOMS position is that such training is not mandatory for all prison staff. However, it is not correct to characterise this as a ‘resource-led’ decision. NOMS is committed to ensuring that a sufficient number of suitably trained first aiders is always available in prisons to enable First Aid to be given to employees, prisoners and visitors. Prison Service Instruction 29/2015 First Aid, issued on 16 November 2015, requires every establishment to carry out a First Aid risk assessment to identify the number of trained first aiders required to provide cover throughout the day.” Source location 2016-0196-Response-by-NOMS
Open published response
26 Oct 2015 Carl Robert FOOT · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 3 Failure to promptly examine cell bell logs and identify those who heard or answered bells View source Lack of information about how long prisoners have been waiting after pressing cell bells View source Inadequate response to cell bells 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
Carl Robert FOOT · 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
Carl Robert Foot was found hanging in his cell at HMP Pentonville after repeatedly ringing his cell bell. He was found at 3.18pm, resuscitated and died four days later in hospital. The jury found that prison officers responded inadequately to the cell bells, contributing to his death, and identified difficulties in determining how long a prisoner had been waiting and in reviewing the incident promptly.
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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to promptly examine cell bell logs and identify those who heard or answered bells
Wider context from the report “3. In terms of learning lessons for the future, which may include learning by individual officers as well as on a systemic basis, there was no exploration immediately after Carl Foot’s death of the cell bell log and all those who heard/answered his bell that afternoon . By the time of inquest, memories had faded .
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of information about how long prisoners have been waiting after pressing cell bells
Wider context from the report “2. Once a cell bell has been pressed, unless they remember hearing it and the time of hearing it, officers on the landing have no way of knowing when the bell was pressed, in other words, how long the prisoner has been waiting . That makes it more difficult to prioritise appropriately .
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Inadequate response to cell bells
Wider context from the report “1. The jury found that there was an inadequate response by prison officers to the cell bells , and that this was a contributory factor in Carl Foot’s death.
” Open source report
16 Sep 2015 Adil HABIB · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 6 Lack of prison officer training on choking risks during searches and control and restraint View source Lack of prison officer training on choking risks during searches and control and restraint View source Failure to provide the attending ambulance service with the prison gate location View source Failure of prison control room officers to immediately provide ambulance access-gate locations to emergency call handlers View source Unavailability of alternative prison-gate information in LAS call-handler systems for other London prisons View source Failure of Hotel 7 nurses to respond immediately to every emergency alarm 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.
×
AI-generated summary
Adil HABIB · 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
Adil Habib died at HMP Pentonville after swallowing a package containing crack cocaine during a search while subject to control and restraint; he choked on it. The inquest recorded the death as accidental, with acute respiratory failure due to mechanical obstruction of the upper airway by a foreign object. A concern was raised that the 999 caller did not immediately provide the prison gate location for attending paramedics, and that ambulance call-handling systems did not then show alternative gates for all London prisons.
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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of prison officer training on choking risks during searches and control and restraint
Wider context from the report “I heard evidence at inquest that there is no training for prison officers that specifically covers the risk of prisoners choking as a result of attempts to conceal an item from prison officers, most especially during a search and/or control & restraint . It seems to me that this is a significant omission , and it would be helpful if such training were mandatory and refreshed regularly. I have written to the National Offender Management Service as provider of prison officer training about this but, in addition, I wanted to bring this direct to your attention. It may be some months before there is any change to the national training offered.
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of prison officer training on choking risks during searches and control and restraint
Wider context from the report “I heard evidence at inquest that there is no training for prison officers that specifically covers the risk of prisoners choking as a result of attempts to conceal an item from prison officers, most especially during a search and/or control & restraint . It seems to me that this is a significant omission, and it would be helpful if such training were mandatory and refreshed regularly.
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to provide the attending ambulance service with the prison gate location
Wider context from the report “When a prison officer at HMP Pentonville rang 999 to ask that paramedics attend the prison, the caller did not immediately offer the location of the prison gate that London Ambulance Service should attend . Whilst there is of course an issue for the prison in terms of offering the information , it would be helpful for LAS call handlers to be provided with a drop down menu showing the alternative gates when they input the prison details.
I understand that the LAS computer system has been augmented in this respect since Mr Habib’s death for HMP Pentonville, but not for the other London prisons. Perhaps that would be a useful exercise?
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure of prison control room officers to immediately provide ambulance access-gate locations to emergency call handlers
Wider context from the report “The prison officer who rang 999 from the control room did not immediately offer the LAS call handler the location of the prison gate to which the ambulance should be driven . I understand that your team has taken steps to remind all officers working in the control room that they must do this. I understand also that your team has an ongoing conversation with London Ambulance Service to enable best care to be given to those in the prison in need of paramedic attention.
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Unavailability of alternative prison-gate information in LAS call-handler systems for other London prisons
Wider context from the report “When a prison officer at HMP Pentonville rang 999 to ask that paramedics attend the prison, the caller did not immediately offer the location of the prison gate that London Ambulance Service should attend. Whilst there is of course an issue for the prison in terms of offering the information, it would be helpful for LAS call handlers to be provided with a drop down menu showing the alternative gates when they input the prison details.
I understand that the LAS computer system has been augmented in this respect since Mr Habib’s death for HMP Pentonville, but not for the other London prisons . Perhaps that would be a useful exercise?
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure of Hotel 7 nurses to respond immediately to every emergency alarm
Wider context from the report “The nurse who was on call as Hotel 7 at the prison did not respond to the emergency alarm that was activated at the start of the control & restraint of Mr Habib, as she should have . Instead, she only responded once a Level 1 emergency was radioed . I appreciate that this nurse no longer works at HMP Pentonville and that your team has taken steps to remind all nurses operating as Hotel 7 of their responsibility to respond to every alarm immediately.
” Open source report
5 Nov 2014 William DAVIES · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 6 Failure of GPs to know that they are allowed to verify death View source Failure to request an ambulance promptly after a level one call View source Unclear responsibility for attending prisoners with life-threatening conditions View source Unclear process for attending prisoners with life-threatening conditions View source Confusion over requesting an ambulance after a level one call View source Failure of prison GPs to understand procedures for verifying death 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.
×
AI-generated summary
William DAVIES · 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
William Davies was found unresponsive in his cell at HMP Pentonville and died from natural causes, identified as coronary artery atherosclerosis. Concerns were raised about unclear procedures and delays in requesting an ambulance after a life-threatening call, as well as uncertainty among prison healthcare staff about responsibilities and verification 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure of GPs to know that they are allowed to verify death
Wider context from the report “There seems to be confusion in the prison regarding the requesting of an ambulance after a level one (i.e. regarding a potentially life threatening situation) call has been made by a prison officer.
The whole process of attending a prisoner with a life threatening condition seemed unclear to the prison general practitioner (now GP lead) giving evidence. She assumed that a prison officer had responsibility for calling an ambulance, but she was not sure.
The GP also did not know that she was allowed to verify the fact of death , and told me that, as a consequence, she carried on with CPR after she knew that Mr Davies had died.
And if the GP lead has not got a good understanding of the procedures in place, then other GPs in the prison may not have either. This could prove fatal, depending upon the circumstances.
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to request an ambulance promptly after a level one call
Wider context from the report “There seems to be confusion in the prison regarding the requesting of an ambulance after a level one (i.e. regarding a potentially life threatening situation) call has been made by a prison officer.
1. I have been told in other inquests (and delay in HMP Pentonville ensuring ambulance attendance has been a feature since the first prison death inquest I heard in Inner North London, on 30 September 2013 ) that prison comms should call an ambulance as soon as they have been notified of a level one .
However, the prison duty governor on the day of Mr Davies’ death, ████████ said that when he arrived two or three minutes after the prison officer who found Mr Davies had contacted comms, no ambulance had been called . ████████ told me that he did not know why this was, though he was duty governor that day and the most senior person from the prison in court.
2. The whole process of attending a prisoner with a life threatening condition seemed unclear to the prison general practitioner (now GP lead) giving evidence. She assumed that a prison officer had responsibility for calling an ambulance, but she was not sure.
The GP also did not know that she was allowed to verify the fact of death, and told me that, as a consequence, she carried on with CPR after she had learnt that Mr Davies had died.
And if the GP lead has not got a good understanding of the procedures in place, then other GPs in the prison may not have either.
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Unclear responsibility for attending prisoners with life-threatening conditions
Wider context from the report “There seems to be confusion in the prison regarding the requesting of an ambulance after a level one (i.e. regarding a potentially life threatening situation) call has been made by a prison officer.
1. I have been told in other inquests (and delay in HMP Pentonville ensuring ambulance attendance has been a feature since the first prison death inquest I heard in Inner North London, on 30 September 2013) that prison comms should call an ambulance as soon as they have been notified of a level one.
However, the prison duty governor on the day of Mr Davies’ death, ████████ said that when he arrived two or three minutes after the prison officer who found Mr Davies had contacted comms, no ambulance had been called. ████████ told me that he did not know why this was, though he was duty governor that day and the most senior person from the prison in court.
2. The whole process of attending a prisoner with a life threatening condition seemed unclear to the prison general practitioner (now GP lead) giving evidence. She assumed that a prison officer had responsibility for calling an ambulance, but she was not sure.
The GP also did not know that she was allowed to verify the fact of death, and told me that, as a consequence, she carried on with CPR after she had learnt that Mr Davies had died.
And if the GP lead has not got a good understanding of the procedures in place, then other GPs in the prison may not have either.
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Unclear process for attending prisoners with life-threatening conditions
Wider context from the report “There seems to be confusion in the prison regarding the requesting of an ambulance after a level one (i.e. regarding a potentially life threatening situation) call has been made by a prison officer.
The whole process of attending a prisoner with a life threatening condition seemed unclear to the prison general practitioner (now GP lead) giving evidence. She assumed that a prison officer had responsibility for calling an ambulance, but she was not sure.
The GP also did not know that she was allowed to verify the fact of death, and told me that, as a consequence, she carried on with CPR after she knew that Mr Davies had died.
And if the GP lead has not got a good understanding of the procedures in place, then other GPs in the prison may not have either. This could prove fatal, depending upon the circumstances.
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Confusion over requesting an ambulance after a level one call
Wider context from the report “There seems to be confusion in the prison regarding the requesting of an ambulance after a level one (i.e. regarding a potentially life threatening situation) call has been made by a prison officer.
The whole process of attending a prisoner with a life threatening condition seemed unclear to the prison general practitioner (now GP lead) giving evidence. She assumed that a prison officer had responsibility for calling an ambulance, but she was not sure.
The GP also did not know that she was allowed to verify the fact of death, and told me that, as a consequence, she carried on with CPR after she knew that Mr Davies had died.
And if the GP lead has not got a good understanding of the procedures in place, then other GPs in the prison may not have either. This could prove fatal, depending upon the circumstances.
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure of prison GPs to understand procedures for verifying death
Wider context from the report “There seems to be confusion in the prison regarding the requesting of an ambulance after a level one (i.e. regarding a potentially life threatening situation) call has been made by a prison officer.
1. I have been told in other inquests (and delay in HMP Pentonville ensuring ambulance attendance has been a feature since the first prison death inquest I heard in Inner North London, on 30 September 2013) that prison comms should call an ambulance as soon as they have been notified of a level one.
However, the prison duty governor on the day of Mr Davies’ death, ████████ said that when he arrived two or three minutes after the prison officer who found Mr Davies had contacted comms, no ambulance had been called. ████████ told me that he did not know why this was, though he was duty governor that day and the most senior person from the prison in court.
2. The whole process of attending a prisoner with a life threatening condition seemed unclear to the prison general practitioner (now GP lead) giving evidence. She assumed that a prison officer had responsibility for calling an ambulance, but she was not sure.
The GP also did not know that she was allowed to verify the fact of death , and told me that, as a consequence, she carried on with CPR after she had learnt that Mr Davies had died.
And if the GP lead has not got a good understanding of the procedures in place, then other GPs in the prison may not have either .
” Open source report
19 Sep 2014 Satheeskumar MAHATHEVAN · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 6 Failure of multi-agency communication procedures View source Failure of multi-agency communication procedures View source Failures in information sharing View source Inadequate training for prison service staff View source Inadequate staff training in prison services View source Failure of information sharing View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Satheeskumar MAHATHEVAN · 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
Satheeskumar Mahathevan hanged himself in his cell at HM Prison Pentonville on 14 April 2013. The report identified concerns about failures in information sharing, multi-agency communication procedures, and inadequate training for prison staff.
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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure of multi-agency communication procedures
Wider context from the report ““Failures in relation to information sharing, multi agency communication procedures and inadequate training for staff at the prison services have contributed to this accident.”
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure of multi-agency communication procedures
Wider context from the report ““Failures in relation to information sharing, multi agency communication procedures and inadequate training for staff at the prison services have contributed to this accident.”
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failures in information sharing
Wider context from the report ““Failures in relation to information sharing , multi agency communication procedures and inadequate training for staff at the prison services have contributed to this accident.”
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Inadequate training for prison service staff
Wider context from the report ““Failures in relation to information sharing, multi agency communication procedures and inadequate training for staff at the prison services have contributed to this accident.”
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Inadequate staff training in prison services
Wider context from the report ““Failures in relation to information sharing, multi agency communication procedures and inadequate training for staff at the prison services have contributed to this accident.”
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure of information sharing
Wider context from the report ““Failures in relation to information sharing , multi agency communication procedures and inadequate training for staff at the prison services have contributed to this accident.”
” Open source report
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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 Obtain prisoners’ consent through an information-sharing form to support necessary information exchange and continuity of care between establishments.
Verbatim wording from the response “On arrival at each prison, prisoners are requested to sign an "information sharing" form, which provides consent for necessary information to be shared as required, so ensuring continuity of care between establishments.” Source location 2014-0412-Response-by-NOMS
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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 Review electronic medical records for transferred prisoners and provide verbal handovers between sending and receiving prisons when wellbeing concerns arise.
Verbatim wording from the response “Both prisons currently use electronic medical records (SystmOne) and on receipt of a prisoner on transfer the healthcare staff in reception read all relevant information on this system to ensure that they are fully aware of their health needs. Where there are concerns with a prisoner’s well-being, the sending prison contacts the receiving prison to ensure that there is a verbal handover in addition to immediate access to the clinical records.” Source location 2014-0412-Response-by-NOMS
Open published response
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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 Implement local information-sharing and multi-agency communication policies, including staff reminders on gathering, assessing and sharing risk information.
Verbatim wording from the response “Local policies are now in place at HMP Pentonville and HMP Thameside to ensure that information is shared appropriately and that there is effective communication between prison staff and the healthcare provider. At both prisons, staff involved in the reception and first night processes have been reminded of the need to gather all relevant information, including information received from court, and of the factors that they should consider when assessing risk and sharing information between agencies.” Source location 2014-0412-Response-by-NOMS
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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 Pentonville healthcare staff to use PNOMIS for recording prisoner information and obtaining community records.
Verbatim wording from the response “All healthcare staff at HMP Pentonville are also being trained in the use of PNOMIS to record prisoner information and made aware of how to obtain community records.” Source location 2014-0412-Response-by-NOMS
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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 Provide Pentonville reception healthcare staff with court documentation and use staged checks and verbal handovers to identify and communicate relevant health-risk information.
Verbatim wording from the response “At HMP Pentonville healthcare staff in reception now have access to all the relevant documents that arrive with the prisoner from court. This will include the prisoner escort record, core record, self harm warning form, custody record from police, and/or F2050 which contains the prisoner’s warrant. The procedure is that on the arrival of a new prisoner the supervising officer on the reception desk checks the accompanying documentation. If any information regarding the prisoner’s physical or mental health is identified this will be handed to the healthcare staff. The prisoner’s file is then passed to staff on the induction wing who conduct a further check of the documentation, providing a second opportunity for relevant information to be found should it have been missed initially.” Source location 2014-0412-Response-by-NOMS
Open published response
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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 Enable prison and healthcare staff at Thameside to work together at reception and use a dedicated form to communicate relevant prisoner information.
Verbatim wording from the response “At HMP Thameside prison and healthcare staff work together at the same counter. A new form has been designed specifically to ensure that all relevant information, including that received from the court, is communicated between the two groups of staff.” Source location 2014-0412-Response-by-NOMS
Open published response
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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 new healthcare staff to use SystmOne correctly and require demonstrated confidence before granting unsupervised access.
Verbatim wording from the response “All new healthcare staff are shown how to use the SystmOne electronic record system correctly, and must be confident in using the system before being allowed access without supervision.” Source location 2014-0412-Response-by-NOMS
Open published response
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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 Routinely request community GP and other relevant health records where prisoners have health concerns, documenting all contact attempts electronically.
Verbatim wording from the response “Community GP records are now routinely requested in all cases in which there are health concerns. All attempts to contact GPs and other relevant agencies are clearly documented on the SystmOne electronic record.” Source location 2014-0412-Response-by-NOMS
Open published response
16 Jun 2014 David Andrew Llewellyn O’GARRO · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 4 Failure to accurately record cell occupancy suitability View source Failure to ensure reliable communication of healthcare cell-sharing instructions to prison officers View source Lack of staff knowledge and shared understanding of cell sharing risk assessment requirements View source Failure to complete and retain cell sharing risk assessments 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.
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AI-generated summary
David Andrew Llewellyn O’GARRO · 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
David Andrew Llewellyn O’Garro suffered a sudden death in epilepsy while occupying a single cell at HMP Pentonville, with nobody present to raise the alarm during what was likely his final seizure. Concerns included the failure to complete or locate a cell sharing risk assessment and a lack of clarity and shared understanding among prison staff about ensuring prisoners with epilepsy had a cellmate.
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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to accurately record cell occupancy suitability
Wider context from the report “The nurse who carried out the first reception screen of Mr O’Garro did not complete a cell sharing risk assessment (CSRA) indicating that he should share a cell, though she told me she knew that a person with epilepsy should not occupy a cell alone. She completed the computer record indicating that he was fit for any cell occupancy.
No HMP Pentonville CSRA was ever found for Mr O’Garro.
During the inquest:
- one prison nurse appeared at times completely unfamiliar with the CSRA, and wholly unclear as to how to ensure (in 2012 or now) that prisoners with epilepsy would have a cellmate;
- a prison doctor said that a locum doctor working at the prison might not even complete a CSRA because s/he would not know how the prison works;
- one of the prison officers was unsure how a message from healthcare regarding cell sharing would reach any particular officer if s/he was away on the day it was entered into the observation book.
Whilst I appreciate that you are making significant changes to the reception process for new prisoners, there appeared at inquest to be a lack of clarity and shared understanding among those working at HMP Pentonville.
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure reliable communication of healthcare cell-sharing instructions to prison officers
Wider context from the report “The nurse who carried out the first reception screen of Mr O’Garro did not complete a cell sharing risk assessment (CSRA) indicating that he should share a cell, though she told me she knew that a person with epilepsy should not occupy a cell alone. She completed the computer record indicating that he was fit for any cell occupancy.
No HMP Pentonville CSRA was ever found for Mr O’Garro.
During the inquest:
- one prison nurse appeared at times completely unfamiliar with the CSRA, and wholly unclear as to how to ensure (in 2012 or now) that prisoners with epilepsy would have a cellmate;
- a prison doctor said that a locum doctor working at the prison might not even complete a CSRA because s/he would not know how the prison works;
- one of the prison officers was unsure how a message from healthcare regarding cell sharing would reach any particular officer if s/he was away on the day it was entered into the observation book.
Whilst I appreciate that you are making significant changes to the reception process for new prisoners, there appeared at inquest to be a lack of clarity and shared understanding among those working at HMP Pentonville.
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of staff knowledge and shared understanding of cell sharing risk assessment requirements
Wider context from the report “The nurse who carried out the first reception screen of Mr O’Garro did not complete a cell sharing risk assessment (CSRA) indicating that he should share a cell, though she told me she knew that a person with epilepsy should not occupy a cell alone. She completed the computer record indicating that he was fit for any cell occupancy.
No HMP Pentonville CSRA was ever found for Mr O’Garro.
During the inquest:
- one prison nurse appeared at times completely unfamiliar with the CSRA, and wholly unclear as to how to ensure (in 2012 or now) that prisoners with epilepsy would have a cellmate ;
- a prison doctor said that a locum doctor working at the prison might not even complete a CSRA because s/he would not know how the prison works ;
- one of the prison officers was unsure how a message from healthcare regarding cell sharing would reach any particular officer if s/he was away on the day it was entered into the observation book.
Whilst I appreciate that you are making significant changes to the reception process for new prisoners, there appeared at inquest to be a lack of clarity and shared understanding among those working at HMP Pentonville .
” 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 Pentonville Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to complete and retain cell sharing risk assessments
Wider context from the report “The nurse who carried out the first reception screen of Mr O’Garro did not complete a cell sharing risk assessment (CSRA) indicating that he should share a cell , though she told me she knew that a person with epilepsy should not occupy a cell alone. She completed the computer record indicating that he was fit for any cell occupancy.
No HMP Pentonville CSRA was ever found for Mr O’Garro .
During the inquest:
- one prison nurse appeared at times completely unfamiliar with the CSRA, and wholly unclear as to how to ensure (in 2012 or now) that prisoners with epilepsy would have a cellmate;
- a prison doctor said that a locum doctor working at the prison might not even complete a CSRA because s/he would not know how the prison works;
- one of the prison officers was unsure how a message from healthcare regarding cell sharing would reach any particular officer if s/he was away on the day it was entered into the observation book.
Whilst I appreciate that you are making significant changes to the reception process for new prisoners, there appeared at inquest to be a lack of clarity and shared understanding among those working at HMP Pentonville.
” 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