15 Feb 2018 Timothy John Shaw · Prevention of Future Deaths report Essex
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Concerns raised 7 Inadequate standard and accuracy of record keeping by disciplinary and healthcare staff View source Inadequate communication between healthcare and disciplinary staff about the purpose of Intelligence Reports View source Inadequate processes and systems for reducing access to illegal substances View source Lack of an appropriate audit system View source Lack of criteria and a system for Intelligence Reports View source Inadequate referral processes to psychosocial services View source Failure of healthcare staff to complete Intelligence Reports correctly 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.
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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 Practice Plus Group Hospitals Limited; 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 Practice Plus Group Hospitals Limited; 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 Practice Plus Group Hospitals Limited; 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 Practice Plus Group Hospitals Limited; 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 Practice Plus Group Hospitals Limited; 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 Practice Plus Group Hospitals Limited; 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 Practice Plus Group Hospitals Limited; 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
17 Feb 2017 Dean Gary Saunders · Prevention of Future Deaths report Essex
View report summary
Concerns raised 8 Failure of the admissions protocol to allow transfer of mentally disordered people from police custody View source Failure to meaningfully involve families in the ACCT process View source Insufficient resilience of psychiatric cover at Chelmsford prison View source Failure to provide effective ACCT process training View source Lack of a written record of the forensic pathway View source Failure to formally record concerns raised by a prisoner’s family View source Failure to communicate concerns raised by a prisoner’s family View source Lack of clarity in the hospital transfer process View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Dean Gary Saunders · 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
Dean Gary Saunders was found unresponsive in his cell at HM Prison Chelmsford on 4 January 2016, and his death was confirmed as electrocution. The inquest identified serious failings in mental health assessment and care, the prison transfer pathway, ACCT assessments and observations, record-keeping and communication, clinical leadership, and family involvement.
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 Practice Plus Group Hospitals Limited; that does not assign responsibility.
PFD Monitor interpretation Failure of the admissions protocol to allow transfer of mentally disordered people from police custody
Wider context from the report “1. FOR SEPT:- The admitted lacuna in the SEPT admissions protocol governing the transfer of mentally disordered people from police custody . The current admissions protocol does not allow for the transfer of any individual from police custody , irrespective of the criminal charges the individual is facing.
” 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 Hospitals Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to meaningfully involve families in the ACCT process
Wider context from the report “6. FOR NOMS:- The meaningful involvement of families in the ACCT process , including by ensuring the formal recording, and communication of concerns raised by a prisoner’s family.
” 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 Hospitals Limited; that does not assign responsibility.
PFD Monitor interpretation Insufficient resilience of psychiatric cover at Chelmsford prison
Wider context from the report “5. FOR NHS ENGLAND:- The resilience of psychiatric cover at Chelmsford prison , which would need to be raised with NHS England who commission such services and decide on the budget.
” 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 Hospitals Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to provide effective ACCT process training
Wider context from the report “4. FOR NOMS:- Training regarding the ACCT process . In previous prison deaths and in response to previous PPO reports, promises have been made about training having been provided to staff yet the same mistakes are being repeated . Meaningful action in required in this regard.
” 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 Hospitals Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of a written record of the forensic pathway
Wider context from the report “2. FOR SEPT AND NHS ENGLAND:- The absence of a written record of the “best practice” forensic pathway referred to by ████████ in his evidence, and consideration of whether the transfer of individuals such as Dean to prison is indeed “best practice”, taking into account the consequent delay in transfer and the suitability of the prison environment for mentally disordered individuals.
” 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 Hospitals Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to formally record concerns raised by a prisoner’s family
Wider context from the report “6. FOR NOMS:- The meaningful involvement of families in the ACCT process, including by ensuring the formal recording , and communication of concerns raised by a prisoner’s family .
” 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 Hospitals Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate concerns raised by a prisoner’s family
Wider context from the report “6. FOR NOMS:- The meaningful involvement of families in the ACCT process, including by ensuring the formal recording, and communication of concerns raised by a prisoner’s family .
” 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 Hospitals Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity in the hospital transfer process
Wider context from the report “3. FOR CARE UK, NOMS, SEPT:- The lack of clarity regarding the hospital transfer process . The evidence at the inquest demonstrated that this is currently shrouded in confusion and contradiction (if the PSI and the NHS England “good practice” is compared). Given that rationalisation of the process is still a “work in progress”, the family consider that it should be given urgent consideration.
” 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 Develop a local Transfer Policy setting out HMP Chelmsford’s processes under the Mental Health Pathway.
Verbatim wording from the response “This revamped Mental Health Pathway is a strategic national policy and local sites develop local operating policies to describe how they will meet the requirements of the pathway. This will include a local Transfer Policy to outline the local processes (see below).” Source location 2017-0056-Response-by-Care-UK
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations