1 Jul 2022 Dominic Robert Noble · Prevention of Future Deaths report West Yorkshire Eastern
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Concerns raised 3 Failure to make psychiatric referrals because of unavailable responding resources View source Delays in providing psychiatrist appointments after assessment referrals View source Insufficient availability of psychiatric doctor provision for the mentally unwell prison population View source
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Dominic Robert Noble · 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
Dominic Robert Noble was remanded to HMP Leeds on terrorist charges and died there on 15 August 2020 as a result of suicide. He had been identified as requiring psychiatric assessment, but remained on a waiting list without an appointment. Concerns included the adequacy of psychiatric provision at HMP Leeds, delays in accessing psychiatric assessment, and the possibility that limited resources discouraged referrals.
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× 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 Practice Plus Group Health And Rehabilitation Services Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to make psychiatric referrals because of unavailable responding resources
Wider context from the report “(3) Concern was expressed in the course of the inquest that the meagre provision of psychiatric consultant availability might deter mental health nurses from making referrals . This concern was not accepted on behalf of PPG. Despite this the concern remains that a self-fulfilling prophecy has inadvertently been created in which referrals are not made because there is no resource to respond to any which may be made .
(4) The concerns raised mirrored issues raised in an inquest which concluded on 1 June 2022 relating to the death of Mohammed Irfaan Afzal in HMP Prison Leeds on 4 August 2019. In a narrative conclusion the jury concluded that despite an urgent referral to a psychiatrist on 15 July 2019, no appointment had been provided before his death on 4 August 2019, “it is possible that the delays in providing treatment contributed more than minimally to Mr Afzal’s death”.
” 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 Practice Plus Group Health And Rehabilitation Services Limited; that does not assign responsibility.
PFD Monitor interpretation Delays in providing psychiatrist appointments after assessment referrals
Wider context from the report “(1) Evidence was taken at the inquest that:
(i) HMP Leeds has only 3 days per week of a psychiatrist's time available
(ii) HMP Leeds has some 5000 prisoners arriving each year.
(iii) A large proportion of the prisoners arriving have mental health issues
(iv) The mental health team is mainly a nurse-led service
(v) The division of labour between mental health nurses and psychiatrists is that a doctor is responsible for the diagnosis of mental illness, prescribing medication such as anti-psychic drugs and seeing prisoners/patients with severe or complex conditions. Mental health nurses make initial assessments and provide ongoing care.
(vi) Concern was expressed about the adequacy of the psychiatric doctor provision to provide psychiatric treatment for a large population which includes men with significant mental health issues.
(vii) Mr Noble was deemed to require assessment by a psychiatrist on 14 July 2020 as a non-urgent case but at the time of his death on 15 August 2020 no appointment had been given.
(viii) A mental health nurse working on behalf of PPG on 10 July 2020 identified the “possibility of emerging psychotic features” and noted the sentiment that engaging in treatment as soon as possible mitigated in favour of a better outcome. Where such a suspicion was raised it would have been advantageous to obtain a second opinion from a psychiatrist swiftly (particularly after his mother contacted the prison to report his paranoid and bizarre conversation regarding a gun, a secret room in the prison and some unknown person trying to kill him.)
” 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 Practice Plus Group Health And Rehabilitation Services Limited; that does not assign responsibility.
PFD Monitor interpretation Insufficient availability of psychiatric doctor provision for the mentally unwell prison population
Wider context from the report “(1) Evidence was taken at the inquest that:
(i) HMP Leeds has only 3 days per week of a psychiatrist's time available
(ii) HMP Leeds has some 5000 prisoners arriving each year.
(iii) A large proportion of the prisoners arriving have mental health issues
(iv) The mental health team is mainly a nurse-led service
(v) The division of labour between mental health nurses and psychiatrists is that a doctor is responsible for the diagnosis of mental illness, prescribing medication such as anti-psychic drugs and seeing prisoners/patients with severe or complex conditions. Mental health nurses make initial assessments and provide ongoing care.
(vi) Concern was expressed about the adequacy of the psychiatric doctor provision to provide psychiatric treatment for a large population which includes men with significant mental health issues.
(vii) Mr Noble was deemed to require assessment by a psychiatrist on 14 July 2020 as a non-urgent case but at the time of his death on 15 August 2020 no appointment had been given.
(viii) A mental health nurse working on behalf of PPG on 10 July 2020 identified the “possibility of emerging psychotic features” and noted the sentiment that engaging in treatment as soon as possible mitigated in favour of a better outcome. Where such a suspicion was raised it would have been advantageous to obtain a second opinion from a psychiatrist swiftly (particularly after his mother contacted the prison to report his paranoid and bizarre conversation regarding a gun, a secret room in the prison and some unknown person trying to kill him.)
” 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 Approach NHS England and discuss seeking additional psychology and psychiatry resource for HMP Leeds.
Verbatim wording from the response “Intended Changes
Following the Learned Coroner’s comments during the inquest into the death of Mr Afzal, ████████, Practice Plus Group’s Regional Director North – Health in Justice, began discussions with Commissioners at NHS England. Whilst Practice Plus Group maintains that the level of psychiatry provision is at least equivalent to that offered in the community, we also recognise that there are significant levels of mental health morbidity in prisons, particularly in a local remand setting such as HMP Leeds. The Learned Coroner’s comments and subsequent report have highlighted a potential need and we have therefore approached our Commissioners for additional resource.” Source location 2022-0204 - Response from Practice Plus Group
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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 Submit a business case to Commissioners for increased psychology and psychiatry provision at HMP Leeds.
Verbatim wording from the response “████████ has discussed with NHS England the submission of a business case for greater psychology and psychiatry provision at HMP Leeds. NHS England, are in principle supportive of increasing the commission of psychology and psychiatry provision at HMP Leeds, but have asked for a West Yorkshire wide mental health service review to be undertaken before any additional investment is made. As budget decisions and funding is the remit of the Commissioners, it is within their gift to request such reviews before business cases are submitted. The review will start once the Regional Mental Health Lead has returned from annual leave. It is anticipated that this will take 2 weeks to carry out with the intention being that a business case is submitted to the Commissioners by the end of September.” Source location 2022-0204 - Response from Practice Plus Group
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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 Even if additional funding is approved, recruitment difficulties may prevent immediate increases in psychiatric provision.
Verbatim wording from the response “HMP Leeds is a high demand remand site and we are seeking additional resource with the aim to improve the number of clinical sessions from 6 to 8 per week. In effect this means that HMP Leeds will need the equivalent of a half-time psychiatrist in addition to what is currently in place in order to achieve the additional clinical sessions. This is due to the non-patient facing time that all directly employed consultant psychiatrists working for Mental Health Trusts have in their contract. These activities include clinical administration tasks (e.g. letters and referrals), service development and training/development.” Source location 2022-0204 - Response from Practice Plus Group
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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 NHS England, as commissioner, is responsible for deciding whether additional psychology and psychiatry resources will be funded.
Verbatim wording from the response “████████ has discussed with NHS England the submission of a business case for greater psychology and psychiatry provision at HMP Leeds. NHS England, are in principle supportive of increasing the commission of psychology and psychiatry provision at HMP Leeds, but have asked for a West Yorkshire wide mental health service review to be undertaken before any additional investment is made. As budget decisions and funding is the remit of the Commissioners, it is within their gift to request such reviews before business cases are submitted. The review will start once the Regional Mental Health Lead has returned from annual leave. It is anticipated that this will take 2 weeks to carry out with the intention being that a business case is submitted to the Commissioners by the end of September.” Source location 2022-0204 - Response from Practice Plus Group
Open published response
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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 stepped-care provision and multidisciplinary referral arrangements are considered sufficient to meet patients’ psychiatric needs at current levels.
Verbatim wording from the response “As in the community, Practice Plus Group delivers a stepped care model, which focuses on providing the most appropriate care for the concerns a patient may have. By adopting this model most people with mental health problems do not need to see a consultant psychiatrist. The stepped care model of mental health focuses on providing people with the right level of support from the right clinician at the right time. For example, people experiencing mild to moderate depression and anxiety would see a primary care mental health clinician in the community, alongside the GP, which is step 2/3.” Source location 2022-0204 - Response from Practice Plus Group
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations