Recipient

Phoenix House

First report 20 Dec 2017•Latest report 15 Feb 2018

Recipient record

Reports, concerns and published responses

Housing · Registered provider of social housing. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 2
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

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

0%published responses found

0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

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

15 Feb2018
Essex
Concerns raised7
1. Inadequate standard and accuracy of record keeping by disciplinary and healthcare staff
2. Inadequate communication between healthcare and disciplinary staff about the purpose of Intelligence Reports
3. Inadequate processes and systems for reducing access to illegal substances
1. Lack of an appropriate audit system
2. Lack of criteria and a system for Intelligence Reports
3. Inadequate referral processes to psychosocial services
4. Failure of healthcare staff to complete Intelligence Reports correctly
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

Timothy John Shaw · 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

Timothy John Shaw, aged 34, was found collapsed in his prison cell on 28 February 2017 after apparent substance use and died in hospital on 2 March 2017. The report identified concerns about communication, intelligence reporting, access to illegal substances, referrals to psychosocial services, and record keeping.

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 Phoenix House; that does not assign responsibility.
PFD Monitor interpretation
Inadequate standard and accuracy of record keeping by disciplinary and healthcare staff
Wider context from the report
“The standard and accuracy of record keeping by both disciplinary and Healthcare staff needs to be improved. ”
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 Phoenix House; that does not assign responsibility.
PFD Monitor interpretation
Inadequate communication between healthcare and disciplinary staff about the purpose of Intelligence Reports
Wider context from the report
“Healthcare staff seemed unclear as to how to fill in an Intelligence Report. There needs to be better communication between Healthcare staff and disciplinary staff as to the purpose of an Intelligence Report. Some criteria need to be developed and a system in place. An appropriate audit system needs to be in place. ”
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 Phoenix House; that does not assign responsibility.
PFD Monitor interpretation
Inadequate processes and systems for reducing access to illegal substances
Wider context from the report
“The processes and systems for reducing access to illegal substances need to be improved and tightened 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 Phoenix House; that does not assign responsibility.
PFD Monitor interpretation
Lack of an appropriate audit system
Wider context from the report
“Healthcare staff seemed unclear as to how to fill in an Intelligence Report. There needs to be better communication between Healthcare staff and disciplinary staff as to the purpose of an Intelligence Report. Some criteria need to be developed and a system in place. An appropriate audit system needs to be in place. ”
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 Phoenix House; that does not assign responsibility.
PFD Monitor interpretation
Lack of criteria and a system for Intelligence Reports
Wider context from the report
“Healthcare staff seemed unclear as to how to fill in an Intelligence Report. There needs to be better communication between Healthcare staff and disciplinary staff as to the purpose of an Intelligence Report. Some criteria need to be developed and a system in place. An appropriate audit system needs to be in place. ”
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 Phoenix House; that does not assign responsibility.
PFD Monitor interpretation
Inadequate referral processes to psychosocial services
Wider context from the report
“The processes for referrals by both prisoners and staff to psychosocial services needs to be tightened up and improved. ”
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 Phoenix House; that does not assign responsibility.
PFD Monitor interpretation
Failure of healthcare staff to complete Intelligence Reports correctly
Wider context from the report
“Healthcare staff seemed unclear as to how to fill in an Intelligence Report. There needs to be better communication between Healthcare staff and disciplinary staff as to the purpose of an Intelligence Report. Some criteria need to be developed and a system in place. An appropriate audit system needs to be in place. ”
Open source report
20 Dec2017
Essex
Concerns raised1
1. Lack of a reliable documentary system for communicating mental health referral information
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

Craig David Royce · 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

Craig Royce, who had a history of mental health problems and epilepsy, was found hanging in his prison cell on 24 December 2016. The report identified concerns that a referral to mental health services following an incident of self-harm was not made and that there was no robust documentary system for communicating such referrals. The inquest jury also considered that his risk of self-harm or suicide was not properly reviewed with appropriate precautions taken.

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 Phoenix House; that does not assign responsibility.
PFD Monitor interpretation
Lack of a reliable documentary system for communicating mental health referral information
Wider context from the report
“There is no form/template to deal with the situation of a prisoner who needs to be referred to the mental health service. Reliance upon the transfer of this vital information to Healthcare by means of a telephone conversation could be unreliable. A robust, simple documentary system is required for the communication of such important information, namely that a prisoner needs to be referred to mental health services for an assessment to be carried out by mental health services. This would be distinct from the TAG system which caters for a brief assessment to be relayed across. ”
Open source report

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

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised7

Inadequate standard and accuracy of record keeping by disciplinary and healthcare staff

Inadequate communication between healthcare and disciplinary staff about the purpose of Intelligence Reports

Inadequate processes and systems for reducing access to illegal substances

Lack of an appropriate audit system

Lack of criteria and a system for Intelligence Reports

Inadequate referral processes to psychosocial services

Failure of healthcare staff to complete Intelligence Reports correctly

Concerns raised1

Lack of a reliable documentary system for communicating mental health referral information