Recipient

Practice Plus Group Hospitals Limited

First report 17 Feb 2017•Latest report 15 Feb 2018

Recipient record

Reports, concerns and published responses

Health and care · Independent healthcare provider. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 2
Published responses: 200%
Concerns addressed: 9
Stated actions: 22

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.

200%published responses found

22stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Practice Plus Group Hospitals Limited 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 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 Feb2017
Essex
Concerns raised8
1. Failure of the admissions protocol to allow transfer of mentally disordered people from police custody
2. Failure to meaningfully involve families in the ACCT process
3. Insufficient resilience of psychiatric cover at Chelmsford prison
1. Failure to provide effective ACCT process training
2. Lack of a written record of the forensic pathway
3. Failure to formally record concerns raised by a prisoner’s family
4. Failure to communicate concerns raised by a prisoner’s family
5. Lack of clarity in the hospital transfer process
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Develop a local Transfer Policy setting out HMP Chelmsford’s processes under the Mental Health Pathway.
  Stated planned
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
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
Page 2 · response
Published 5 March 2017
Open published response

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

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns 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 raised8

Failure of the admissions protocol to allow transfer of mentally disordered people from police custody

Failure to meaningfully involve families in the ACCT process

Insufficient resilience of psychiatric cover at Chelmsford prison

Failure to provide effective ACCT process training

Lack of a written record of the forensic pathway

Failure to formally record concerns raised by a prisoner’s family

Failure to communicate concerns raised by a prisoner’s family

Lack of clarity in the hospital transfer process

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

Actions described in response 1