7 May 2026 Alan Joseph Whelan · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 1 Failure to provide a mental health assessment within 24 hours of transfer to the Segregation Unit for prisoners on an open ACCT document 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
Alan Joseph Whelan · 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
Alan Whelan, a serving prisoner at HMP Leeds, was moved to the Segregation Unit after starting a fire in his cell while on an open ACCT document. A required mental health assessment was not carried out within 24 hours, and he was later found hanging in his cell and died in hospital on 30 December 2024. Concerns included non-compliance with the mandatory assessment requirement and failures relating to the frequency of ACCT observations.
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; that does not assign responsibility.
PFD Monitor interpretation Failure to provide a mental health assessment within 24 hours of transfer to the Segregation Unit for prisoners on an open ACCT document
Wider context from the report “A mandatory requirement that a prisoner on an open ACCT document should have a mental health assessment within 24 hours of being transferred to the Segregation Unit was not complied with. Alan took steps that caused his death after that 24-hour window had closed. There was scant acknowledgement of this breach of a standing instruction from the witnesses who gave evidence to the inquest. The possibility that not carrying out such an assessment made no difference to the outcome is obvious. But that possibility neither explains nor excuses the failure to comply with the instruction , especially where it is unclear whether that failure was inadvertent or deliberate, and if deliberate, with what justification.
” Open source report
7 Apr 2026 Mark Robert Smith · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 9 Failure to ensure truthful observation records View source Failure to maintain QEH staff awareness of the limits of prison healthcare View source Failure to coordinate prison discharge through an MDT and relevant prison healthcare liaison View source Failure to prescribe and administer medication at the correct dose View source Failure to ensure safe and clearly understood medication-system operation View source Failure to record the cell-entry escalation process in policy View source Failure to maintain prison and healthcare staff awareness of the cell-entry escalation process View source Failure to complete required patient observations View source Unavailability of larger disabled cells adapted for constant watch 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 Robert Smith · 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 Robert Smith, who was detained at HMP Thameside, died after an epileptic seizure led to cardiac arrest. The report describes concerns about medication prescribing and administration, hospital-to-prison discharge and communication, access to his cell, observation arrangements and records, staffing, and the lack of equipment for resuscitation.
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; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure truthful observation records
Wider context from the report “(5) I am concerned there were numerous missed and falsified observation entries in Mark’s case and how similar incidents can be prevented given the reliance on handwritten sheets being scanned onto the system at a later stage . I appreciate the efforts made with training and audits. (Practice Plus Group)
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain QEH staff awareness of the limits of prison healthcare
Wider context from the report “(2) I remain concerned a similar situation could arise as did in Mark’s case regarding a discharge back to prison from QEH without an MDT meeting despite repeated requests from prison healthcare and there could be a risk to life. I note PFD evidence provided regarding improved liaison between QEH and the prison GP but note no reference to liaison between QEH and the head of the healthcare in prison, who visited QEH twice in Mark’s case.
Further, as recently as 2025 an incident occurred when there was a lack of understanding at QEH around the limited provision in healthcare in prison . I am concerned as to how awareness of the limits of prison healthcare will be disseminated on a continuing basis to new and locum staff at QEH . (QEH and Practice Plus Group)
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure to coordinate prison discharge through an MDT and relevant prison healthcare liaison
Wider context from the report “(2) I remain concerned a similar situation could arise as did in Mark’s case regarding a discharge back to prison from QEH without an MDT meeting despite repeated requests from prison healthcare and there could be a risk to life. I note PFD evidence provided regarding improved liaison between QEH and the prison GP but note no reference to liaison between QEH and the head of the healthcare in prison , who visited QEH twice in Mark’s case.
Further, as recently as 2025 an incident occurred when there was a lack of understanding at QEH around the limited provision in healthcare in prison. I am concerned as to how awareness of the limits of prison healthcare will be disseminated on a continuing basis to new and locum staff at QEH. (QEH and Practice Plus Group)
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure to prescribe and administer medication at the correct dose
Wider context from the report “(1) The wrong dose of medication could be prescribed and/or administered with life threatening consequences. Albeit I have seen evidence of significant improvements in prescribing practice at HMP Thameside since 2019 (e.g HMIP report February 2026); as recently as 2024 to 2025 HMIP and IMB reports noted “significant risks with management of medicines” and “prescribing errors.” Whilst recent internal audits in 2025 show significant improvements, medication incidents (datix) are recorded in late 2025 and the principal pharmacist notes a very busy site with multiple prescriptions screened daily.
Further, during the inquest it proved difficult to establish how Systm 1 (the medical note system) operated and whether there were risks inherent in the system itself. For example, it was suggested the system would convert mg into ml or pre-populate entries such as 100ml, in contradiction to the subsequent PFD evidence provided. (Practice Plus Group)
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure safe and clearly understood medication-system operation
Wider context from the report “(1) The wrong dose of medication could be prescribed and/or administered with life threatening consequences. Albeit I have seen evidence of significant improvements in prescribing practice at HMP Thameside since 2019 (e.g HMIP report February 2026); as recently as 2024 to 2025 HMIP and IMB reports noted “significant risks with management of medicines” and “prescribing errors.” Whilst recent internal audits in 2025 show significant improvements, medication incidents (datix) are recorded in late 2025 and the principal pharmacist notes a very busy site with multiple prescriptions screened daily.
Further, during the inquest it proved difficult to establish how Systm 1 (the medical note system) operated and whether there were risks inherent in the system itself . For example, it was suggested the system would convert mg into ml or pre-populate entries such as 100ml , in contradiction to the subsequent PFD evidence provided. (Practice Plus Group)
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure to record the cell-entry escalation process in policy
Wider context from the report “(3) Healthcare staff may be unable to enter a prisoner’s cell at night and monitor them in a situation which may not constitute a “medical emergency” but in which a patient nevertheless requires attention; a patient could decline and the situation become life threatening. I have received detail from Serco of “an escalation process” if Oscar 1 and Hotel 1 cannot agree about entry to a cell and I have been told this has been “recommunicated” to all staff. However, this is not recorded in a policy. I am concerned about awareness of the process for all prison and healthcare staff including on an ongoing basis. (Serco and Practice Plus Group).
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain prison and healthcare staff awareness of the cell-entry escalation process
Wider context from the report “(3) Healthcare staff may be unable to enter a prisoner’s cell at night and monitor them in a situation which may not constitute a “medical emergency” but in which a patient nevertheless requires attention; a patient could decline and the situation become life threatening. I have received detail from Serco of “an escalation process” if Oscar 1 and Hotel 1 cannot agree about entry to a cell and I have been told this has been “recommunicated” to all staff. However, this is not recorded in a policy. I am concerned about awareness of the process for all prison and healthcare staff including on an ongoing basis. (Serco and Practice Plus Group).
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure to complete required patient observations
Wider context from the report “(5) I am concerned there were numerous missed and falsified observation entries in Mark’s case and how similar incidents can be prevented given the reliance on handwritten sheets being scanned onto the system at a later stage. I appreciate the efforts made with training and audits. (Practice Plus Group)
” 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; that does not assign responsibility.
PFD Monitor interpretation Unavailability of larger disabled cells adapted for constant watch
Wider context from the report “(4) There are no larger disabled cells (which can accommodate hospital beds and wheelchairs) adapted to also facilitate a constant watch. Security concerns, in this might not be possible, and a similar situation might occur to that in Mark’s case. (HMPPS)
” Open source report
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.
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. 5
Action
Hold a June 2026 meeting with regional and nursing directors to review guidance, consider further scoping, and assess safe ILS/ROLE staffing levels.
Stated plannedThe respondent said that this action was planned when they made their response on 10 April 2026. View source
Action
Publish and implement the purple-alert guidance clarifying BLS, ILS, ROLE, and CPR expectations, and remind staff of its application.
Stated completedThe respondent said that this action was complete when they made their response on 10 April 2026. View source
Action
Deliver annual RCUK-accredited ILS training including ROLE, audit compliance, and restrict emergency-radio assignment for staff whose training is out of date.
Stated completedThe respondent said that this action was complete when they made their response on 10 April 2026. View source
Action
Introduce multidisciplinary, scenario-based resuscitation training for healthcare, prison, and prison-officer staff by July 2026.
Stated in progressThe respondent said that this action was in progress when they made their response on 10 April 2026. View source
Action
Deliver the booked ILS training session to increase current training compliance above 90%.
Stated plannedThe respondent said that this action was planned when they made their response on 10 April 2026. View source See 2 more actions
×
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 Practice Plus Group; 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 Practice Plus Group; 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 Practice Plus Group; 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 Practice Plus Group; 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 Practice Plus Group; 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 Practice Plus Group; 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 Practice Plus Group; 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 Practice Plus Group; 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 Practice Plus Group; 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 Practice Plus Group; 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 Practice Plus Group; 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 Practice Plus Group; 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
×
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 Hold a June 2026 meeting with regional and nursing directors to review guidance, consider further scoping, and assess safe ILS/ROLE staffing levels.
Verbatim wording from the response “In light of the Prevention of Future Deaths (PFD) report, the site has also requested a meeting with the Regional Director and the Director of Nursing, due to be held in June 2026. The purpose of this meeting is to:” Source location Response from Practice Plus Group
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 Publish and implement the purple-alert guidance clarifying BLS, ILS, ROLE, and CPR expectations, and remind staff of its application.
Verbatim wording from the response “A purple alert (which is a companywide safety notification) was published for all Heads of Healthcare to action, which clarified the organisational position on cardiopulmonary resuscitation following updated guidance by NHSE on 19 March 2026, which is being actioned in line with the deadline given in the alert. A copy of this alert is attached to this response for ease of reference. The purple alert highlights to all services within Practice Plus Group (PPG) that we fully support the national HMPPS/NHS England guidance that cardiopulmonary resuscitation (CPR) should begin immediately when an individual is unresponsive, not breathing and/or has no pulse, unless there are unmistakable signs of irreversible death. However, it recognises that PPG’s clinical training model differs from the national assumption that prison healthcare staff are trained only to Basic Life Support (BLS) level.” Source location Response from Practice Plus Group
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 Deliver annual RCUK-accredited ILS training including ROLE, audit compliance, and restrict emergency-radio assignment for staff whose training is out of date.
Verbatim wording from the response “It is important to note that all clinical staff are trained to ILS (Immediate Life Support) standards. This is a RCUK accredited course for healthcare professionals to manage patients in cardiac arrest before the ambulance team arrives. It focuses on the ABCDE approach, airway management, and safe defibrillation. All staff are expected to complete this training which is done yearly to ensure ongoing competence. This is also subject to audit, which currently shows a 74% compliance rate. Anyone who does not have the training in date would not be assigned to an emergency radio and would be expected to book and complete the training as soon as possible. There is a session booked on the week commencing 25th June 2026 which will raise the compliance to over 90%.” Source location Response from Practice Plus Group
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 Introduce multidisciplinary, scenario-based resuscitation training for healthcare, prison, and prison-officer staff by July 2026.
Verbatim wording from the response “As a service, we are committed to further strengthening our resuscitation response following the issues highlighted in the PFD. To support this, we are introducing multidisciplinary, scenario-based training by July 2026. This programme will involve healthcare staff, prison staff, and prison officers where appropriate, ensuring that learning is shared across the whole custodial environment and that all parties understand their roles during a medical” Source location Response from Practice Plus Group
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 Deliver the booked ILS training session to increase current training compliance above 90%.
Verbatim wording from the response “It is important to note that all clinical staff are trained to ILS (Immediate Life Support) standards. This is a RCUK accredited course for healthcare professionals to manage patients in cardiac arrest before the ambulance team arrives. It focuses on the ABCDE approach, airway management, and safe defibrillation. All staff are expected to complete this training which is done yearly to ensure ongoing competence. This is also subject to audit, which currently shows a 74% compliance rate. Anyone who does not have the training in date would not be assigned to an emergency radio and would be expected to book and complete the training as soon as possible. There is a session booked on the week commencing 25th June 2026 which will raise the compliance to over 90%.” Source location Response from Practice Plus Group
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 Responsibility for the concerns about HMPPS and HMP Pentonville rests with separate organisations, so no response is proposed.
Verbatim wording from the response “We do not propose to respond to the points raised above in respect of HMPPS and HMP Pentonville as these matters are for separate organisation.” Source location Response from Practice Plus Group
Open published response
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
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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.
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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; 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 Practice Plus Group; 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 Practice Plus Group; 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 Practice Plus Group; 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 Practice Plus Group; 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 Practice Plus Group; 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 Practice Plus Group; 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 Practice Plus Group; 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 Practice Plus Group; 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
×
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 Use a weekly national forum to review medium- and high-risk patient-safety incidents and determine the appropriate learning response.
Verbatim wording from the response “In respect of investigations undertaken by PPG generally, the organisation has strengthened its governance arrangements to support more consistent and balanced decision-making regarding the appropriate level of investigation. A weekly national decision-making forum has been introduced to review medium to high-risk patient safety incidents and determine appropriate level of learning response i.e. whether a Patient Safety Incident Investigation (PSII) or other structured review methodology is required.” Source location Response from Practice Plus Group (1)
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 senior clinical leaders to provide quality assurance and sign-off for all patient-safety incident investigations.
Verbatim wording from the response “In addition, senior clinical leaders now provide quality assurance and sign-off for all patient safety incident investigations to ensure appropriate clinical scrutiny, learning and response to incidents.” Source location Response from Practice Plus Group (1)
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 Continue seeking staff perspectives from significant or recent patient interactions during death-in-custody and other incident reviews.
Verbatim wording from the response “As part of the processes staff involved in the patient’s care are spoken to, interviewed or asked for statements so that their perspectives are taken into consideration. We will continue to seek the views of staff who had significant interactions with patients involved in a DIC or other incident, as well as those who may have been the last or latter interactions.” Source location Response from Practice Plus Group (1)
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 Provide investigation training, guidance and support to improve systems-based investigation capability and report quality.
Verbatim wording from the response “In addition, we are prioritising improvements in the quality and consistency of patient safety investigations and reporting. Training, guidance and support are being provided to staff involved in investigations to strengthen capability in systems-based investigation methodologies and improve the clarity and quality of investigation reports.” Source location Response from Practice Plus Group
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 Operate a multidisciplinary Professional Decisions Panel to oversee professional practice and fitness-to-practise concerns.
Verbatim wording from the response “As part of strengthening governance arrangements, we also established a HiJ Triage Professional Decisions Panel (PDP) in early 2025. The PDP provides multidisciplinary oversight and guidance where concerns arise relating to professional practice or fitness to practise. The panel enables cases to be reviewed holistically with senior clinical input and supports proportionate and consistent decision-making regarding professional conduct concerns.” Source location Response from Practice Plus Group
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 Review incident learning through national patient safety and quality assurance governance forums to identify emerging themes across services.
Verbatim wording from the response “The centralisation of the Patient Safety Team has enabled a more structured approach to reviewing learning from individual patient safety incidents and identifying emerging themes across services. Learning identified through incident reviews is now considered through strengthened national” Source location Response from Practice Plus Group
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 Operate a weekly national forum to determine appropriate learning responses for medium- and high-risk patient safety incidents.
Verbatim wording from the response “In response, the organisation has strengthened its governance arrangements to support more consistent and balanced decision-making regarding the appropriate level of investigation. A weekly national decision-making forum has been introduced to review medium to high-risk patient safety incidents and determine appropriate level of learning response i.e., whether a Patient Safety Incident Investigation (PSII) or other structured review methodology is required.” Source location Response from Practice Plus Group
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 Centralise the Patient Safety Team to strengthen oversight, consistency and identification of cross-site safety themes.
Verbatim wording from the response “In August 2025, PPG HiJ directorate further strengthened its patient safety governance arrangements through the centralisation of the Patient Safety Team. The purpose of this change was to improve organisational oversight of patient safety incidents across services, enhance the consistency and quality of incident management and investigation, and strengthen the organisation’s ability to identify emerging safety themes across multiple sites.” Source location Response from Practice Plus Group
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 Cross-reference learning from external reviews with internal patient safety incident reviews.
Verbatim wording from the response “The organisation has also introduced a centralised process to cross-reference learning from external review mechanisms, including Prisons and Probation Ombudsman investigations and independent clinical reviewer reports, ensuring that learning identified through external processes is considered alongside internal incident reviews.” Source location Response from Practice Plus Group
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 senior clinical leaders to provide quality assurance and sign-off for all patient safety investigations.
Verbatim wording from the response “In addition, senior clinical leaders now provide quality assurance and sign-off for all patient safety incident investigations to ensure appropriate clinical scrutiny, learning and response to incidents.” Source location Response from Practice Plus Group
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 Responsibility for concerns about HMPPS and HMP Pentonville rests with separate organisations, so no response is proposed.
Verbatim wording from the response “We do not propose to respond to the points raised above in respect of HMPPS and HMP Pentonville as these matters are for separate organisations.” Source location Response from Practice Plus Group (1)
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 Responsibility for Phoenix Futures’ service and employees rests with Phoenix Futures, which is expected to respond separately.
Verbatim wording from the response “Likewise, the points raised under the heading for Phoenix and PPG mainly relate to Phoenix Futures and the steps taken by one of their employees. Whilst we work closely with Phoenix as one of our subcontractors at Pentonville and work together to improve services and continue our strong working partnership, we do not propose to comment on their service or individual employees. We understand that Phoenix will be responding to the points raised separately.” Source location Response from Practice Plus Group (1)
Open published response
10 Mar 2026 Surendrakumar Patel · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 8 Failure to consider and advocate for family contact View source Delays in full medical assessment by a senior healthcare professional View source Failure to inform Next of Kin of a prisoner’s decision to refuse food or fluids View source Lack of prison staff awareness of the HMP Hewell food refusal policy View source Lack of healthcare staff awareness of the food refusal policy View source Failure to recognise when mental capacity assessment is required after food refusal begins View source Failure to ask the prisoner whether food refusal information should be shared View source Failure to consider hospital transfer for prisoners severely weakened by weight loss View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Surendrakumar Patel · 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
Surendrakumar Patel died at Alexandra Hospital, Redditch, on 31 October 2024 after collapsing with a lower respiratory tract infection, with self-neglect through malnutrition contributing to his death. While on remand at HMP Hewell, he stopped eating, expressed that he no longer wished to live, lost weight, and developed acute kidney injury. The report identified concerns about healthcare staff’s failure to recognise the need for a timely mental capacity assessment, consider hospital transfer and expedited senior medical and psychiatric assessment, and consider family contact; prison staff also lacked awareness of procedures for informing or consulting next of kin about food refusal.
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; that does not assign responsibility.
PFD Monitor interpretation Failure to consider and advocate for family contact
Wider context from the report “1. Healthcare staff (MPFT and PPG) lacked awareness of the food refusal policy:
a. Failure to recognise that a mental capacity assessment was required as soon as food refusal began
b. Failure to consider hospital transfer for prisoners severely weakened by weight loss
c. Failure to expedite full medical assessment by a senior healthcare professional, including psychiatric assessment where physical health posed a risk to survival
d. Failure to consider and advocate for family contact
2. Prison staff lacked awareness of HMP Hewell food refusal policy, including:
• Not informing Next of Kin of the prisoner’s decision to refuse food/fluids
• Not asking the prisoner whether such information should be shared
” 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; that does not assign responsibility.
PFD Monitor interpretation Delays in full medical assessment by a senior healthcare professional
Wider context from the report “1. Healthcare staff (MPFT and PPG) lacked awareness of the food refusal policy:
a. Failure to recognise that a mental capacity assessment was required as soon as food refusal began
b. Failure to consider hospital transfer for prisoners severely weakened by weight loss
c. Failure to expedite full medical assessment by a senior healthcare professional, including psychiatric assessment where physical health posed a risk to survival
d. Failure to consider and advocate for family contact
2. Prison staff lacked awareness of HMP Hewell food refusal policy, including:
• Not informing Next of Kin of the prisoner’s decision to refuse food/fluids
• Not asking the prisoner whether such information should be shared
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure to inform Next of Kin of a prisoner’s decision to refuse food or fluids
Wider context from the report “1. Healthcare staff (MPFT and PPG) lacked awareness of the food refusal policy:
a. Failure to recognise that a mental capacity assessment was required as soon as food refusal began
b. Failure to consider hospital transfer for prisoners severely weakened by weight loss
c. Failure to expedite full medical assessment by a senior healthcare professional, including psychiatric assessment where physical health posed a risk to survival
d. Failure to consider and advocate for family contact
2. Prison staff lacked awareness of HMP Hewell food refusal policy, including:
• Not informing Next of Kin of the prisoner’s decision to refuse food/fluids
• Not asking the prisoner whether such information should be shared
” 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; that does not assign responsibility.
PFD Monitor interpretation Lack of prison staff awareness of the HMP Hewell food refusal policy
Wider context from the report “1. Healthcare staff (MPFT and PPG) lacked awareness of the food refusal policy:
a. Failure to recognise that a mental capacity assessment was required as soon as food refusal began
b. Failure to consider hospital transfer for prisoners severely weakened by weight loss
c. Failure to expedite full medical assessment by a senior healthcare professional, including psychiatric assessment where physical health posed a risk to survival
d. Failure to consider and advocate for family contact
2. Prison staff lacked awareness of HMP Hewell food refusal policy , including:
• Not informing Next of Kin of the prisoner’s decision to refuse food/fluids
• Not asking the prisoner whether such information should be shared
” 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; that does not assign responsibility.
PFD Monitor interpretation Lack of healthcare staff awareness of the food refusal policy
Wider context from the report “1. Healthcare staff (MPFT and PPG) lacked awareness of the food refusal policy :
a. Failure to recognise that a mental capacity assessment was required as soon as food refusal began
b. Failure to consider hospital transfer for prisoners severely weakened by weight loss
c. Failure to expedite full medical assessment by a senior healthcare professional, including psychiatric assessment where physical health posed a risk to survival
d. Failure to consider and advocate for family contact
2. Prison staff lacked awareness of HMP Hewell food refusal policy, including:
• Not informing Next of Kin of the prisoner’s decision to refuse food/fluids
• Not asking the prisoner whether such information should be shared
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise when mental capacity assessment is required after food refusal begins
Wider context from the report “1. Healthcare staff (MPFT and PPG) lacked awareness of the food refusal policy:
a. Failure to recognise that a mental capacity assessment was required as soon as food refusal began
b. Failure to consider hospital transfer for prisoners severely weakened by weight loss
c. Failure to expedite full medical assessment by a senior healthcare professional, including psychiatric assessment where physical health posed a risk to survival
d. Failure to consider and advocate for family contact
2. Prison staff lacked awareness of HMP Hewell food refusal policy, including:
• Not informing Next of Kin of the prisoner’s decision to refuse food/fluids
• Not asking the prisoner whether such information should be shared
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure to ask the prisoner whether food refusal information should be shared
Wider context from the report “1. Healthcare staff (MPFT and PPG) lacked awareness of the food refusal policy:
a. Failure to recognise that a mental capacity assessment was required as soon as food refusal began
b. Failure to consider hospital transfer for prisoners severely weakened by weight loss
c. Failure to expedite full medical assessment by a senior healthcare professional, including psychiatric assessment where physical health posed a risk to survival
d. Failure to consider and advocate for family contact
2. Prison staff lacked awareness of HMP Hewell food refusal policy, including:
• Not informing Next of Kin of the prisoner’s decision to refuse food/fluids
• Not asking the prisoner whether such information should be shared
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure to consider hospital transfer for prisoners severely weakened by weight loss
Wider context from the report “1. Healthcare staff (MPFT and PPG) lacked awareness of the food refusal policy:
a. Failure to recognise that a mental capacity assessment was required as soon as food refusal began
b. Failure to consider hospital transfer for prisoners severely weakened by weight loss
c. Failure to expedite full medical assessment by a senior healthcare professional, including psychiatric assessment where physical health posed a risk to survival
d. Failure to consider and advocate for family contact
2. Prison staff lacked awareness of HMP Hewell food refusal policy, including:
• Not informing Next of Kin of the prisoner’s decision to refuse food/fluids
• Not asking the prisoner whether such information should be shared
” 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 Deliver national talks in July 2026 on recent food-and-fluid cases and the need to follow the pathway fully.
Verbatim wording from the response “reason for the food and fluid refusal. In addition to local feedback to the primary healthcare staff at HMP Hewell following the outcome of the Inquest, Practice Plus Group has planned to roll out a series of talks nationally across the Group in July 2026 to feedback on the recent high profile food and fluid cases they have been involved in, and to reinforce the need to follow the food and fluid pathway in full.” Source location Response from Practice Plus Group
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 Provide local feedback to primary healthcare staff on the inquest outcome and food-and-fluid refusal pathway.
Verbatim wording from the response “reason for the food and fluid refusal. In addition to local feedback to the primary healthcare staff at HMP Hewell following the outcome of the Inquest, Practice Plus Group has planned to roll out a series of talks nationally across the Group in July 2026 to feedback on the recent high profile food and fluid cases they have been involved in, and to reinforce the need to follow the food and fluid pathway in full.” Source location Response from Practice Plus Group
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 The food and fluid refusal pathway is considered robust and fit for purpose regardless of the reason for refusal.
Verbatim wording from the response “This does not mean that Practice Plus Group has not reflected on this case. The outcome of the Inquest follows a period whereupon the food and fluid refusal pathway has robustly been tested and, as a result, Practice Plus Group considers it to be robust and fit for purpose regardless of the” Source location 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 Family advocacy was not considered necessary because the patient did not request family support and no benefit from contact was identified.
Verbatim wording from the response “So far as Practice Plus Group is concerned, Mr Patel did not request any family support. Mr Patel told the nursing staff that his only external support had been his wife and that he was not in contact with his daughter at the time he entered HMP Hewell. Therefore, the need to act as an advocate for family contact did not arise in this specific case.” Source location Response from Practice Plus Group
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 There was no clinical reason to believe the patient lacked capacity to refuse food, fluids or other offered care.
Verbatim wording from the response “Practice Plus Group welcomes the opportunity to respond to the concerns raised by HM Assistant Coroner. The circumstances of this case were complex. Mr Patel arrived in prison in a malnourished state which the Inquest heard had been an ongoing chronic issue for him dating back at least one year. Further, and whilst Mr Patel was remanded at HMP Hewell, at no time was he found to lack capacity to refuse food and fluids and /or proposed medical assessments. This meant that, when assessments and food and fluid was offered and declined, the healthcare staff were required, pursuant to the Mental Capacity Act 2009, to respect the wishes of Mr Patel. This was reflected in the conclusion reached by the Jury that Surendra Patel died from natural causes contributed to by self-neglect by malnutrition.” Source location Response from Practice Plus Group
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 A formal capacity assessment would not necessarily have changed the care provided, according to the clinical reviewer.
Verbatim wording from the response “It is of note that the clinical reviewer commented when giving evidence at the Inquest that she did consider the referral had been made as soon as was practically possible and, in any event, even if a formal Mental Capacity Act assessment had taken place, she was not convinced it would have made any difference to the care provided.” Source location Response from Practice Plus Group
Open published response
Concerns raised 2 Delays of many months in access to psychologist support View source Lack of psychologist resource for prisoners View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Aaron Lee Taylor · 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
Aaron Lee Taylor was discovered suspended from a ligature in his cell at HMP Garth on 28 August 2023. The inquest concluded that he had taken steps intending to take his own life and identified multiple failures in suicide-prevention measures, mental-health interventions, assessments, documentation, and adherence to policies and procedures.
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; that does not assign responsibility.
PFD Monitor interpretation Delays of many months in access to psychologist support
Wider context from the report “Evidence was heard that PPG Healthcare who are now responsible for healthcare at HMP Garth have not had any psychologist resource for prisoners at HMP Garth unless they have been victims of sexual assault. Even then, evidence was heard about waiting lists of many months . Evidence was also heard that a decision had not been taken to fill psychologist resource gaps by locum cover, despite those gaps having existed for 6 months
” 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; that does not assign responsibility.
PFD Monitor interpretation Lack of psychologist resource for prisoners
Wider context from the report “Evidence was heard that PPG Healthcare who are now responsible for healthcare at HMP Garth have not had any psychologist resource for prisoners at HMP Garth unless they have been victims of sexual assault . Even then, evidence was heard about waiting lists of many months. Evidence was also heard that a decision had not been taken to fill psychologist resource gaps by locum cover, despite those gaps having existed for 6 months
” 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 Recruit and establish the new Principal, Clinical Assistant and Assistant Psychologist roles to increase psychology capacity at HMP Garth.
Verbatim wording from the response “Response:
The current model of psychology provision at HMP Garth consists of a 1 part-time Principal Psychologist, 1 full-time Clinical Assistant Psychologist and 2 full time Assistant Psychologists. All of these posts are new roles following TUPE of services and all posts are out to advert.” Source location Response from Practice Plus Group
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 Provide routine psychological support and safety-netting through Health and Wellbeing Practitioners and Nurse Associates, with monitoring and escalation to mental health nurses.
Verbatim wording from the response “Patients requiring routine psychology interventions who are not case loaded to a mental health nurse are provided with support from a Health and Wellbeing Practitioner and Nurse Associate, this provides ongoing support and safety-netting to patients, including monitoring and escalation to the Mental Health nursing team if required. Upon escalation they can then be case-managed by a Mental Health nurse. No further patients are being added to the waiting list while we await appointment of the psychologists. Anyone who is now referred for psychological services is allocated a health and well-being practitioner, who can undertake a lot of low level work that can be done in meantime, in preparation for psychological input.” Source location Response from Practice Plus Group
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 Seek interim agency locum cover for the Principal Psychologist vacancy.
Verbatim wording from the response “The Consultant Clinical Psychologist has contacted agencies to backfill the Principal Psychologist role in the interim. Unfortunately, no suitable locum psychologist has been available to be provided by the agency, due to a lack of psychologists in the employment market.” Source location Response from Practice Plus Group
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 Stop adding patients to the psychology waiting list while psychologist recruitment is pending and allocate new referrals interim health and wellbeing support.
Verbatim wording from the response “Patients requiring routine psychology interventions who are not case loaded to a mental health nurse are provided with support from a Health and Wellbeing Practitioner and Nurse Associate, this provides ongoing support and safety-netting to patients, including monitoring and escalation to the Mental Health nursing team if required. Upon escalation they can then be case-managed by a Mental Health nurse. No further patients are being added to the waiting list while we await appointment of the psychologists. Anyone who is now referred for psychological services is allocated a health and well-being practitioner, who can undertake a lot of low level work that can be done in meantime, in preparation for psychological input.” Source location Response from Practice Plus Group
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 Provide urgent psychological support through local and regional multidisciplinary case conferences and the established regional psychology workforce.
Verbatim wording from the response “Patients requiring urgent psychological interventions are discussed at a multi professional complex case conference (MPCCC) at a local level and referred to the Regional MPCCC for review and care planning. Provision is in place to ensure urgent patients are provided with psychological support from the region’s established psychology workforce.” Source location Response from Practice Plus Group
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 Locum psychologist cover cannot currently be provided because suitable psychologists are unavailable in the employment market.
Verbatim wording from the response “The Consultant Clinical Psychologist has contacted agencies to backfill the Principal Psychologist role in the interim. Unfortunately, no suitable locum psychologist has been available to be provided by the agency, due to a lack of psychologists in the employment market.” Source location Response from Practice Plus Group
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 Interim routine and urgent psychology support, including monitoring, escalation and regional provision, is in place while psychologist posts are filled.
Verbatim wording from the response “Patients requiring routine psychology interventions who are not case loaded to a mental health nurse are provided with support from a Health and Wellbeing Practitioner and Nurse Associate, this provides ongoing support and safety-netting to patients, including monitoring and escalation to the Mental Health nursing team if required. Upon escalation they can then be case-managed by a Mental Health nurse. No further patients are being added to the waiting list while we await appointment of the psychologists. Anyone who is now referred for psychological services is allocated a health and well-being practitioner, who can undertake a lot of low level work that can be done in meantime, in preparation for psychological input.” Source location Response from Practice Plus Group
Open published response
20 Oct 2025 Ms. Amy Jo Cross · Prevention of Future Deaths report Avon
View report summary
Concerns raised 2 Lack of a system for passing important healthcare information between criminal justice healthcare providers during conveyance View source Lack of a standard medical records system accessible to each healthcare organisation 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
Ms. Amy Jo Cross · 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
Ms. Amy Jo Cross was arrested on 9 June 2023, experienced reported drug and alcohol withdrawal symptoms, and died in a prison cell on 10 June 2023 after being found unresponsive before prescribed medication was administered. The report identified concerns about the transfer of healthcare information, including recent medication administration and physical observations, between police, court and prison healthcare providers, and the absence of a shared medical records system.
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; that does not assign responsibility.
PFD Monitor interpretation Lack of a system for passing important healthcare information between criminal justice healthcare providers during conveyance
Wider context from the report “(1) There is no system to ensure that important healthcare information including recent administration of medicines and the results of physical observations is passed between separate providers of healthcare in the criminal justice system at the time a person is conveyed between the police, the court and the prison.
” 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; that does not assign responsibility.
PFD Monitor interpretation Lack of a standard medical records system accessible to each healthcare organisation
Wider context from the report “(2) There is no standard medical records system which can be accessed by each healthcare organisation to ensure the efficient and effective transfer of medical information.
” Open source report
13 Oct 2025 Jamie Stuart Funnell · Prevention of Future Deaths report East Sussex
View report summary
Concerns raised 3 Inadequate life support training for healthcare staff View source Failure to monitor life support equipment for faults View source Failure to review, clarify and update Standard Operating Procedures before expiry View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jamie Stuart Funnell · 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
Jamie Stuart Funnell died at HMP Lewes on 16 December 2023 while withdrawing from alcohol and drugs. The inquest concluded that his death was due to the effects of drug and alcohol withdrawal, exacerbated by omissions by healthcare and prison staff. Concerns included failures in withdrawal assessment and monitoring, communication, CPR response, staff training, equipment maintenance, and updating relevant procedures.
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; that does not assign responsibility.
PFD Monitor interpretation Inadequate life support training for healthcare staff
Wider context from the report “2. I heard evidence describing the care given to Jamie Funnell after his collapse as chaotic, with faulty equipment and incorrect CPR technique . The Ambulance crews witnessed the healthcare members carrying out CPR before taking over. After Jamie’s death was confirmed, a crew member raised concerns with the Duty Governor about the CPR attempts she had witnessed.
I have heard evidence that although 32 eligible healthcare staff have now completed life support training, I have not heard any evidence regarding the level of this training and remain concerned, especially in light of the unsatisfactory response by PPG in its Action Plan for the PFO Report dated September 2024 that adequate training of staff and monitoring of equipment to prevent faults in its operation have been undertaken to prevent a fatality occurring in similar 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 Practice Plus Group; that does not assign responsibility.
PFD Monitor interpretation Failure to monitor life support equipment for faults
Wider context from the report “2. I heard evidence describing the care given to Jamie Funnell after his collapse as chaotic, with faulty equipment and incorrect CPR technique. The Ambulance crews witnessed the healthcare members carrying out CPR before taking over. After Jamie’s death was confirmed, a crew member raised concerns with the Duty Governor about the CPR attempts she had witnessed.
I have heard evidence that although 32 eligible healthcare staff have now completed life support training, I have not heard any evidence regarding the level of this training and remain concerned, especially in light of the unsatisfactory response by PPG in its Action Plan for the PFO Report dated September 2024 that adequate training of staff and monitoring of equipment to prevent faults in its operation have been undertaken to prevent a fatality occurring in similar 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 Practice Plus Group; that does not assign responsibility.
PFD Monitor interpretation Failure to review, clarify and update Standard Operating Procedures before expiry
Wider context from the report “1.The Standard Operating Procedure for Assessment and Management of Alcohol Dependence expired in March 2024. I heard evidence that it will be replaced by an updated Policy on 9.10.25. I asked for a copy of the draft Policy to determine whether issuing a PPD could be avoided when hearing evidence about PFD matters but was advised by the PPG’s legal representative that this was not possible, without a reason why being offered.
I consider that action should be taken to prevent a failure to update before their expiry all PPG’s Standard Operating Procedures including this one which the Clinical Reviewer found to be potentially unclear . His findings were published on 19.4.24, a month after the Standard Operating Procedure had expired, and yet it continues to remain out of date, almost 18 months later . PPG could have reasonably expected it would be subject to scrutiny in this inquest and update it accordingly and in a timely manner. Their failure to do so indicates a cavalier attitude to reviewing and updating important Policies and action should be taken to address this.
” 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 Provide annual accredited Immediate Life Support training for relevant staff, with agency staff required to hold current certification and compliance monitored monthly.
Verbatim wording from the response “At HMP Lewes, all of our substantive and bank nursing staff, GP staff and health care assistants receive annual Immediate Life Support training which is accredited with the Resuscitation Council UK. Agency staff receive annual training through their employing agency and are not able to work at Practice Plus Group sites without having an in-date certificate of completion. Current compliance figures for Immediate Life Support training are 96% which is monitored monthly so that timely courses can be booked to ensure staff remain up to date.” Source location Response from Practice Plus Group
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 Replace the expired alcohol-dependence SOP with ratified clinical guidance incorporating clearer monitoring, escalation, transfer, omitted-dose and documentation requirements.
Verbatim wording from the response “Standard Operating Procedure for Assessment and Management of Alcohol Dependence
Please find the enclosed clinical guidance document for ‘Assessment and Management of Alcohol Dependence’. We can confirm that this was ratified at a Governance meeting on 9 October 2025.” Source location Response from Practice Plus Group
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 Implement fortnightly emergency-bag checks, daily seal checks, monthly audits and bimonthly dip tests to verify equipment readiness and drug validity.
Verbatim wording from the response “Emergency bag equipment is checked every 2 weeks by the team to ensure that they contain the correct equipment, that the equipment works and that emergency drugs are in date. After each check, the bags are resealed and the seals are checked daily on site to ensure they remain intact. The emergency bag check process is audited monthly as per the Practice Plus Group annual audit schedule and in line with the Emergency Response Policy for Healthcare Professionals within Health in Justice sites (ratified January 2024 and due for review March 2026). In addition to the regular bag checks, we have also implemented bimonthly dip tests of the emergency response bags to provide further reassurance.” Source location Response from Practice Plus Group
Open published response
28 May 2025 Samuel Anthony Donald STEWART · Prevention of Future Deaths report West London
View report summary
Concerns raised 2 Failure to support and discuss positive drug test results with prisoners View source Failure to ensure clear and followed pathways for action after a positive drug test View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Samuel Anthony Donald STEWART · 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
Samuel Stewart was found deceased in his cell at HMP Wormwood Scrubs on 15 July 2023, with drugs paraphernalia in the cell. His death was due to drugs in combination with long-term cardiac damage. A positive drug test on 6 March 2023 was not followed by discussion, support, or a multidisciplinary meeting, and the pathways after a positive result were unclear or not followed.
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; that does not assign responsibility.
PFD Monitor interpretation Failure to support and discuss positive drug test results with prisoners
Wider context from the report “Sam had elected to have a place on a "drug free" wing and accepted the conditions of this placement. He accessed non-prescribed drugs (amphetamines) as his test on 6 March 2023 yielded a positive result. No action was taken by either the prison or healthcare.
(1) consideration should be given as to what actions should have been taken, and if this is set out in the national or local policy guidelines
(2) pathways after a positive test result were either not followed or unclear
(3) An opportunity was missed to support Sam and discuss this with 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; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure clear and followed pathways for action after a positive drug test
Wider context from the report “Sam had elected to have a place on a "drug free" wing and accepted the conditions of this placement. He accessed non-prescribed drugs (amphetamines) as his test on 6 March 2023 yielded a positive result. No action was taken by either the prison or healthcare.
(1) consideration should be given as to what actions should have been taken, and if this is set out in the national or local policy guidelines
(2) pathways after a positive test result were either not followed or unclear
(3) An opportunity was missed to support Sam and discuss this with him
” 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 Operate a clinical pathway for communicated positive drug tests, including medication checks, clinical substance-misuse review, confirmatory screening, assessment, incident reporting and an individual care plan.
Verbatim wording from the response “However, Practice Plus Group, and the wider healthcare team at HMP Wormwood Scrubs, do have a process in place when positive results are communicated to us. For context, whilst Practice Plus Group provide the primary healthcare services and clinical substance misuse services, Forward Trust provide non-clinical substance misuse (Psychosocial) services and North London NHS Foundation Trust (formally Barnet, Enfield and Haringey NHS Trust) provide secondary mental health services. We have outlined the steps which would be taken below:” Source location 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 Healthcare was not aware of the positive test because prison staff did not communicate it, so healthcare was not in a position to act.
Verbatim wording from the response “Response: We consider it is important to outline at the outset that in this case healthcare was unfortunately not made aware of the positive test and therefore were not in a position to take” Source location Response from Practice Plus Group
Open published response
4 Dec 2024 Kayleigh Ann MELHUISH · Prevention of Future Deaths report Avon
View report summary
Concerns raised 5 Failure by healthcare staff to check and update ACCT care plan support actions during reviews View source Ligature point where the Residential Unit 3 privacy screen meets the wall View source Failure to complete or review ACCT care plans and support actions at every review View source Lack of understanding of when and how constant supervision can be used View source Lack of mandatory neurodiversity training for prison staff 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
Kayleigh Ann MELHUISH · 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
Kayleigh Ann Melhuish died on 7 July 2022 after being found hanging in her cell at HMP Eastwood Park and later taken to hospital. The report identifies concerns about staff understanding of neurodiversity, completion of ACCT care plans and support actions, use of constant supervision, and a ligature point in Residential Unit 3. The inquest concluded that suspension by a ligature contributed to the death by neglect.
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; that does not assign responsibility.
PFD Monitor interpretation Failure by healthcare staff to check and update ACCT care plan support actions during reviews
Wider context from the report “2. Healthcare (AWP and PPG): training issues arose in relation to, when attending ACCT reviews that they check the care plan with support actions part of the document is reviewed and if necessary updated ; it was suggested that consideration could be made to making changes to the system-one database to check this step has been taken.
” 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; that does not assign responsibility.
PFD Monitor interpretation Ligature point where the Residential Unit 3 privacy screen meets the wall
Wider context from the report “3. To HMP Eastwood: the ligature point in Residential Unit 3 where the privacy screen meets the wall .
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure to complete or review ACCT care plans and support actions at every review
Wider context from the report “1. To HMP Eastwood Park and The Ministry of Justice - training issues in relation to the following areas for new and existing staff:
a. Neurodiversity, I am told 75% of women in prison have mental health or neurodiverse issues, this training is not mandatory;
b. ACCT, there was little understanding of the requirement to complete or review the care plan and support actions at every ACCT review not just the planned reviews ;
c. Little or no understanding of when constant supervision can be used and how is it used;
” 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; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of when and how constant supervision can be used
Wider context from the report “1. To HMP Eastwood Park and The Ministry of Justice - training issues in relation to the following areas for new and existing staff:
a. Neurodiversity, I am told 75% of women in prison have mental health or neurodiverse issues, this training is not mandatory;
b. ACCT, there was little understanding of the requirement to complete or review the care plan and support actions at every ACCT review not just the planned reviews;
c. Little or no understanding of when constant supervision can be used and how is it used ;
” 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; that does not assign responsibility.
PFD Monitor interpretation Lack of mandatory neurodiversity training for prison staff
Wider context from the report “1. To HMP Eastwood Park and The Ministry of Justice - training issues in relation to the following areas for new and existing staff:
a. Neurodiversity, I am told 75% of women in prison have mental health or neurodiverse issues, this training is not mandatory ;
b. ACCT, there was little understanding of the requirement to complete or review the care plan and support actions at every ACCT review not just the planned reviews;
c. Little or no understanding of when constant supervision can be used and how is it used;
” Open source report
16 Jan 2024 Trevor Alan MONERVILLE · Prevention of Future Deaths report East Sussex
View report summary
Concerns raised 6 Lack of a mechanism to report medication non-compliance to Security View source Lack of prison staff training in managing long-term health conditions on the wings View source Failure of the CSRA policy to protect prisoners with relevant medical conditions View source Lack of individualized seizure care planning and monitoring View source Inadequate communication about prisoners’ health conditions View source Deficit in national policy for managing and supporting prisoners with epilepsy and seizures 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
Trevor Alan MONERVILLE · 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
Trevor Alan Monerville, who had been detained at HMP Lewes, was found unresponsive in his cell on 18 April 2021 and died after suffering from epilepsy and non-epileptic attack disorder. The principal concerns were inadequate monitoring and management of his epilepsy after the ACCT closed, poor communication and information-sharing between healthcare, prison staff and family, and insufficient staff training in managing epilepsy and seizures.
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; that does not assign responsibility.
PFD Monitor interpretation Lack of a mechanism to report medication non-compliance to Security
Wider context from the report “b. Communication between healthcare and prison staff especially when Trevor was returned to the wing, between the prison staff and family, briefing by prison managers to officers on the wing about Trevor’s condition were all inadequate.
Evidence was heard about the lack of integration of various IT systems which contributed to poor communication. In spite of the evidence from PPG regarding the sensitivity of medical records which should not be disclosed to the prison staff, I remain concerned that there was no effective monitoring and management of Trevor on the wing once the ACCT was closed. There was no mechanism in place for prison and healthcare staff to report their concerns about Trevor’s non compliance with taking his medication to Security , thus preventing the cell from being searched for retained medication.
” 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; that does not assign responsibility.
PFD Monitor interpretation Lack of prison staff training in managing long-term health conditions on the wings
Wider context from the report “c. There was a lack of training of prison staff in dealing with long term health conditions such as epilepsy on the wings. I understand there is a deficit in national policy within the prison service to manage and support prisoners with epilepsy and seizures.
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure of the CSRA policy to protect prisoners with relevant medical conditions
Wider context from the report “a. Consideration should be given to the review of the treatment, monitoring and management of patients with a history of epilepsy or seizures by both the prison staff and healthcare staff. In particular, there was no seizure care plan, no seizure diary and once the ACCT had closed on 10th March 2021, there was no formal mechanism of monitoring Trevor’s condition. Further, the ACCT is not a suitable mechanism for such monitoring. The CSRA policy is designed to protect other prisoners, but not those who suffer from medical conditions as Trevor suffered. PPG in their evidence to be considered relating to PFD matters state that a care plan dashboard is now in place at HMP Lewes but this does not appear to be individualized or tailored to the prisoner’s clinical requirements.
” 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; that does not assign responsibility.
PFD Monitor interpretation Lack of individualized seizure care planning and monitoring
Wider context from the report “a. Consideration should be given to the review of the treatment, monitoring and management of patients with a history of epilepsy or seizures by both the prison staff and healthcare staff. In particular, there was no seizure care plan, no seizure diary and once the ACCT had closed on 10th March 2021, there was no formal mechanism of monitoring Trevor’s condition . Further, the ACCT is not a suitable mechanism for such monitoring. The CSRA policy is designed to protect other prisoners, but not those who suffer from medical conditions as Trevor suffered. PPG in their evidence to be considered relating to PFD matters state that a care plan dashboard is now in place at HMP Lewes but this does not appear to be individualized or tailored to the prisoner’s clinical requirements .
” 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; that does not assign responsibility.
PFD Monitor interpretation Inadequate communication about prisoners’ health conditions
Wider context from the report “b. Communication between healthcare and prison staff especially when Trevor was returned to the wing , between the prison staff and family , briefing by prison managers to officers on the wing about Trevor’s condition were all inadequate.
Evidence was heard about the lack of integration of various IT systems which contributed to poor communication. In spite of the evidence from PPG regarding the sensitivity of medical records which should not be disclosed to the prison staff, I remain concerned that there was no effective monitoring and management of Trevor on the wing once the ACCT was closed. There was no mechanism in place for prison and healthcare staff to report their concerns about Trevor’s non compliance with taking his medication to Security, thus preventing the cell from being searched for retained medication.
” 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; that does not assign responsibility.
PFD Monitor interpretation Deficit in national policy for managing and supporting prisoners with epilepsy and seizures
Wider context from the report “c. There was a lack of training of prison staff in dealing with long term health conditions such as epilepsy on the wings. I understand there is a deficit in national policy within the prison service to manage and support prisoners with epilepsy and seizures.
” Open source report
12 Oct 2023 Mr Jonathan Michael McCarthy · Prevention of Future Deaths report Northamptonshire
View report summary
Concerns raised 4 Failure to determine the clinical importance and urgency of pre-existing community hospital appointments in light of security issues View source Failure to verify prisoners’ pre-existing community hospital appointments View source Failure to determine medical hold View source Failure to assess fitness to transfer View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mr Jonathan Michael McCarthy · 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 Jonathan Michael McCarthy died on 12 August 2018 at University Hospital Coventry and Warwickshire from a cardiac arrhythmia associated with scarring of the heart, while at HMP Onley. Concerns included failures to verify and assess the clinical importance of pre-existing community hospital appointments, the impact of security issues on those appointments, and whether he was fit to transfer or should have been placed on medical hold.
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; that does not assign responsibility.
PFD Monitor interpretation Failure to determine the clinical importance and urgency of pre-existing community hospital appointments in light of security issues
Wider context from the report “Upon Mr McCarthy’s arrival at HMP Altcourse on 5 June 2017, it is recorded that he had an outstanding hospital appointment. There was no evidence that HMP Altcourse took any steps to verify this appointment.
Mr McCarthy was transferred to HMP Thameside on 7 May 2018. It is recorded that he had an appointment to see the cardiologist at Whittington Hospital on 13 June 2018. There was no evidence that HMP Thameside took any steps to verify this appointment. He was transferred from the prison on the next day, 14th June 2018.
It was suggested in evidence that HMP Thameside automatically re-arrange all community medical appointments for security reasons. It was clarified that the prison would only try to get a new appointment if there was a specific security concern.
There was also no evidence that Mr McCarthy had a fitness to transfer assessment at either HMP Altcourse or HMP Thameside.
1. verifying a prisoner’s pre-existing community hospital appointments.
2. determining the clinical importance/urgency of pre-existing community hospital appointments and the impact of security issues upon this assessment.
3. assessing fitness to transfer and determining medical hold.
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure to verify prisoners’ pre-existing community hospital appointments
Wider context from the report “Upon Mr McCarthy’s arrival at HMP Altcourse on 5 June 2017, it is recorded that he had an outstanding hospital appointment. There was no evidence that HMP Altcourse took any steps to verify this appointment.
Mr McCarthy was transferred to HMP Thameside on 7 May 2018. It is recorded that he had an appointment to see the cardiologist at Whittington Hospital on 13 June 2018. There was no evidence that HMP Thameside took any steps to verify this appointment. He was transferred from the prison on the next day, 14th June 2018.
It was suggested in evidence that HMP Thameside automatically re-arrange all community medical appointments for security reasons. It was clarified that the prison would only try to get a new appointment if there was a specific security concern.
There was also no evidence that Mr McCarthy had a fitness to transfer assessment at either HMP Altcourse or HMP Thameside.
1. verifying a prisoner’s pre-existing community hospital appointments.
2. determining the clinical importance/urgency of pre-existing community hospital appointments and the impact of security issues upon this assessment.
3. assessing fitness to transfer and determining medical hold.
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure to determine medical hold
Wider context from the report “Upon Mr McCarthy’s arrival at HMP Altcourse on 5 June 2017, it is recorded that he had an outstanding hospital appointment. There was no evidence that HMP Altcourse took any steps to verify this appointment.
Mr McCarthy was transferred to HMP Thameside on 7 May 2018. It is recorded that he had an appointment to see the cardiologist at Whittington Hospital on 13 June 2018. There was no evidence that HMP Thameside took any steps to verify this appointment. He was transferred from the prison on the next day, 14th June 2018.
It was suggested in evidence that HMP Thameside automatically re-arrange all community medical appointments for security reasons. It was clarified that the prison would only try to get a new appointment if there was a specific security concern.
There was also no evidence that Mr McCarthy had a fitness to transfer assessment at either HMP Altcourse or HMP Thameside.
1. verifying a prisoner’s pre-existing community hospital appointments.
2. determining the clinical importance/urgency of pre-existing community hospital appointments and the impact of security issues upon this assessment.
3. assessing fitness to transfer and determining medical hold.
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure to assess fitness to transfer
Wider context from the report “Upon Mr McCarthy’s arrival at HMP Altcourse on 5 June 2017, it is recorded that he had an outstanding hospital appointment. There was no evidence that HMP Altcourse took any steps to verify this appointment.
Mr McCarthy was transferred to HMP Thameside on 7 May 2018. It is recorded that he had an appointment to see the cardiologist at Whittington Hospital on 13 June 2018. There was no evidence that HMP Thameside took any steps to verify this appointment. He was transferred from the prison on the next day, 14th June 2018.
It was suggested in evidence that HMP Thameside automatically re-arrange all community medical appointments for security reasons. It was clarified that the prison would only try to get a new appointment if there was a specific security concern.
There was also no evidence that Mr McCarthy had a fitness to transfer assessment at either HMP Altcourse or HMP Thameside.
1. verifying a prisoner’s pre-existing community hospital appointments.
2. determining the clinical importance/urgency of pre-existing community hospital appointments and the impact of security issues upon this assessment.
3. assessing fitness to transfer and determining medical hold.
” 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 Clinically triage patients arriving with external appointments and assign urgency categories to determine whether appointments are kept, delivered remotely, cancelled, or re-referred.
Verbatim wording from the response “As part of the LOP noted above, HMP Thameside have put in place a process in which all patients who arrive with external appointments are highlighted to the GP/ANP or senior nurse to clinically triage. When considering the urgency of the appointment, multiple factors are taken into consideration. This includes what the appointment is for, whether it can be delivered on site, and if it needs transferring to a local hospital. Once a priority category has been has been allocated, admin are informed whether the appointment needs to be kept, can be moved to remote or can be cancelled and re-referred. The priority categories are urgent, routine and non-urgent or follow up.” Source location Response from Practice Plus Group
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 Place patients receiving local-hospital treatment or urgent or specialised appointments on medical hold until treatment or appointments are completed.
Verbatim wording from the response “Those undergoing treatment at a local hospital would be placed on “Medical Hold” in order for the treatment to be completed. If a patient has to be transferred, a Transfer of Care letter is sent with them to their new establishment which includes all appointments and reasons for them. This process is documented in the Transfer of Care LOP, which all staff have been made aware of. Our transfer process is detailed further below.” Source location Response from Practice Plus Group
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 Review medical holds regularly and communicate them directly to the prison.
Verbatim wording from the response “Medical Holds are communicated directly with the prison and reviewed on a regular basis by healthcare.” Source location Response from Practice Plus Group
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 Undertake and record a fitness-to-transfer assessment for every patient before transfer to an establishment or court.
Verbatim wording from the response “All patients will have a fitness to transfer assessment undertaken prior to transfer to any establishment or court, this is recorded on SystmOne and forms part of the transfer process. Healthcare are generally notified 24 hours prior to release or transfer of a patient. This can vary depending on external factors such as Court listings and timings.” Source location Response from Practice Plus Group
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 Responsibility for arranging escorts to external appointments lies with the prison, not healthcare.
Verbatim wording from the response “If the patient has transferred in from another prison establishment then they would not be aware of the date of any external appointments. As noted at the Inquest, this is for security reasons. In such circumstances it is much easier for the appointment to be kept and it would not be cancelled unless for a security reason. Contact would still be made with the external provider to ensure that the appointment is still scheduled and then the prison would be informed accordingly so that escorts can be arranged. Escorts to external appointments fall to the prison and is not the responsibility of healthcare.” Source location Response from Practice Plus Group
Open published response
3 Oct 2023 Manoel Messias Santos · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 10 Failure to provide timely notification of immigration detention before release View source Delays and failures by the SSHD in progressing FNO cases and obtaining required information View source Delays by probation in allocating community offender managers and providing up-to-date OASYS reports View source Absence of a prison offender manager specialist model for FNO immigration liaison View source Failure to facilitate and signpost access to immigration legal advice View source Failure of communication between immigration and sentence-planning agencies View source Persistent misunderstanding of the policy governing OSG officers opening cell doors at night View source Insufficient communication of entitlement to free immigration legal advice View source Lack of clear systems for obtaining medical information View source Failure to disseminate and action important learning points View source See 7 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Manoel Messias Santos · 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
Manoel Messias Santos, a Brazilian national detained in prison and facing immigration detention and possible deportation, was found hanging in his cell in the early hours of 2 November 2020 and was declared dead at 3.30am. The jury found that his understanding of his immigration position made a material contribution to his death and identified failures in notifying him about the IS91 notice and communicating his immigration position. The report also raised concerns about delays in notification and case handling, access to legal advice, communication between agencies, dissemination of learning, and staff understanding of the policy on opening cell doors at night.
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; that does not assign responsibility.
PFD Monitor interpretation Failure to provide timely notification of immigration detention before release
Wider context from the report “2. The timing of the notification to Mr Santos by the SSHD that he was not to be released at the end of his custodial sentence but was to be held on immigration detention pending a decision on deportation. The SSHD target for notification is 30 days prior to release. In this case it was 8 days late. I heard PFD evidence that this 30-day target is not met in 40% of cases and that 83% of cases are notified within 7 days of the end of the sentence . I am concerned at the potential uncertainty and distress caused to Foreign National Offenders (“FNOs”) by notification at this stage.
” 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; that does not assign responsibility.
PFD Monitor interpretation Delays and failures by the SSHD in progressing FNO cases and obtaining required information
Wider context from the report “8. I am concerned at the potential impact of delays/failure to obtain information in other cases. In Mr Santos’ case there were delays by probation in allocating a community offender manager and providing an up-to-date OASYS report. There were also delays by the SSHD progressing Mr Santos’ case , including issue of the Stage 2 letter , failure to obtain medical records and delay in requesting the OASYS report .
9. I am encouraged that there is now a centralised system (and form) for the SSHD to request OASYS reports from probation although it is not clear the extent to which requests are going through this system. Consent to obtain medical information is sought from FNOs at an induction meeting by Immigration Prison Teams (“IPTs”). Further IPT officers attend prisons and play a key role in obtaining this type of information. However it is not clear what systems are in place to facilitate the obtaining of medical information.
” 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; that does not assign responsibility.
PFD Monitor interpretation Delays by probation in allocating community offender managers and providing up-to-date OASYS reports
Wider context from the report “8. I am concerned at the potential impact of delays/failure to obtain information in other cases. In Mr Santos’ case there were delays by probation in allocating a community offender manager and providing an up-to-date OASYS report . There were also delays by the SSHD progressing Mr Santos’ case, including issue of the Stage 2 letter, failure to obtain medical records and delay in requesting the OASYS report.
9. I am encouraged that there is now a centralised system (and form) for the SSHD to request OASYS reports from probation although it is not clear the extent to which requests are going through this system. Consent to obtain medical information is sought from FNOs at an induction meeting by Immigration Prison Teams (“IPTs”). Further IPT officers attend prisons and play a key role in obtaining this type of information. However it is not clear what systems are in place to facilitate the obtaining of medical information.
” 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; that does not assign responsibility.
PFD Monitor interpretation Absence of a prison offender manager specialist model for FNO immigration liaison
Wider context from the report “6. Communication issues between the agencies dealing with immigration and sentence planning may lead to confusion and uncertainty for FNOs.
7. I appreciate that any legal advice for FNOs should be from a legal adviser. I am encouraged that the probation service (who employ community offender managers) is seeking to develop a cohort of probation officers specialising in FNOs and immigration. There are now 201 SPOCs across 12 regions and a hub lead developing this model and leading engagement with the SSHD. There is no such model in the prison in respect of “prison offender managers” who also liaise with the SSHD about FNOs.
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure to facilitate and signpost access to immigration legal advice
Wider context from the report “4. I am concerned as to how access to legal advice is facilitated and signposted.
5. In PFD evidence, I was informed that FNOs (in a similar position to Mr Santos) are now entitled to 30 minutes of free legal advice following a High Court decision in February 2021. In HMP Belmarsh, this entitlement is displayed on a notice in each Houseblock. I am concerned that displaying a notice is insufficient to draw this entitlement to the attention of FNOs. I do not know if this is a wider issue in other prisons. Understanding of immigration status, including appeal and bail procedures and is complex. Access to legal advice is vital to prevent confusion.
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure of communication between immigration and sentence-planning agencies
Wider context from the report “6. Communication issues between the agencies dealing with immigration and sentence planning may lead to confusion and uncertainty for FNOs.
7. I appreciate that any legal advice for FNOs should be from a legal adviser. I am encouraged that the probation service (who employ community offender managers) is seeking to develop a cohort of probation officers specialising in FNOs and immigration. There are now 201 SPOCs across 12 regions and a hub lead developing this model and leading engagement with the SSHD. There is no such model in the prison in respect of “prison offender managers” who also liaise with the SSHD about FNOs.
” 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; that does not assign responsibility.
PFD Monitor interpretation Persistent misunderstanding of the policy governing OSG officers opening cell doors at night
Wider context from the report “13. In evidence there was a continued misunderstanding that the policy did not apply to Operational Support Grade (OSG) officers and it was understood that they should never open cell doors at night . This was despite the PPO report dated December 2021 (at paragraph 73) requesting this be addressed.
14. The prison stated in PFD evidence that all staff will be instructed as to the policy in terms of opening cell doors at night (which requires a dynamic risk assessment).
15. I remain concerned that this appears to be a longstanding belief held by experienced officers .
” 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; that does not assign responsibility.
PFD Monitor interpretation Insufficient communication of entitlement to free immigration legal advice
Wider context from the report “4. I am concerned as to how access to legal advice is facilitated and signposted.
5. In PFD evidence, I was informed that FNOs (in a similar position to Mr Santos) are now entitled to 30 minutes of free legal advice following a High Court decision in February 2021. In HMP Belmarsh, this entitlement is displayed on a notice in each Houseblock. I am concerned that displaying a notice is insufficient to draw this entitlement to the attention of FNOs. I do not know if this is a wider issue in other prisons. Understanding of immigration status, including appeal and bail procedures and is complex. Access to legal advice is vital to prevent confusion.
” 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; that does not assign responsibility.
PFD Monitor interpretation Lack of clear systems for obtaining medical information
Wider context from the report “8. I am concerned at the potential impact of delays/failure to obtain information in other cases. In Mr Santos’ case there were delays by probation in allocating a community offender manager and providing an up-to-date OASYS report. There were also delays by the SSHD progressing Mr Santos’ case, including issue of the Stage 2 letter, failure to obtain medical records and delay in requesting the OASYS report.
9. I am encouraged that there is now a centralised system (and form) for the SSHD to request OASYS reports from probation although it is not clear the extent to which requests are going through this system. Consent to obtain medical information is sought from FNOs at an induction meeting by Immigration Prison Teams (“IPTs”). Further IPT officers attend prisons and play a key role in obtaining this type of information. However it is not clear what systems are in place to facilitate the obtaining of medical information.
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure to disseminate and action important learning points
Wider context from the report “10. The SSHD disclosed an Internal report into Mr Santos’ case midway through the Inquest, which was not on his Home Office file. The lawyers representing the SSHD were unaware of this report. The head of FNO Returns Command only became aware of it the preceding week and understood it had been disclosed.
11. The report detailed delays and issues in Mr Santos’ case and the SSHD then made formal admissions of the relevant (non-causative) failures which where recorded by the jury in the Record of Inquest at my direction.
12. This report was dated February 2021 and listed action points for the relevant department. Although I am told that these are now being addressed, I am concerned that important learning points (which could prevent future deaths) were not disseminated and actioned as they should have been.
” 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 Share lessons learned from the inquest across Practice Plus Group services.
Verbatim wording from the response “Practice Plus Group is committed to ensuring the high quality provision of healthcare services to all prisoners at HMP Belmarsh. We will also ensure that the lessons learnt as a result of this inquest are shared across all of Practice Plus Group’s services.” Source location Response from Practice Plus Group
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 Practice Plus Group cannot respond directly to improving communication between immigration, sentence-planning and prison agencies because the matter relates to other agencies.
Verbatim wording from the response “There are now 201 SPOCs across the 12 regions and a hub lead developing this model and leading engagement with the SSHD. There is no such model in the prison in respect of “prison offender managers” who also liaise with the SSHD about FNOs.” Source location Response from Practice Plus Group
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 Concerns about immigration notifications, legal advice, agency delays, report disclosure and night cell-door opening do not relate to healthcare functions.
Verbatim wording from the response “There are a number of concerns raised in your report which relate to the timing of the IS91 notification, the signposting for legal advice about immigration matters, delays by SSHD and probation, the disclosure of SSHD internal reports and the opening of cell doors at night. As these matters do not relate to healthcare and PPG we do not propose to respond.” Source location Response from Practice Plus Group
Open published response
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.
×
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 Practice Plus Group; 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 Practice Plus Group; 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 Practice Plus Group; 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 Practice Plus Group; 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 Practice Plus Group; 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
×
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 the Early Days quality-assurance process, including passport checks, multidisciplinary review, task tracking and completion sign-off before patients leave the system.
Verbatim wording from the response “Q: What strikes me is if that happened on that day, what is happening with all the other prisoners?
A: Since then [AS’s death] changes have been made to the reception process, on each side. There has been a big focus on early days in custody, recognising that the first 14 days and particularly the first couple of days are the most important period in someone’s stay in prison. One of things that would identify poor completion of cell sharing risk assessment is early day passport. This is overseen by custodial managers and nursing staff. There is a checklist to ensure that everything mandatory within the process has been completed and completed to a good standard. Definitely if not completed to good standard would expect that to be flagged to me.
Q: Who is doing this?
A: Custodial managers.” Source location Response from Practice Plus Group
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 Provide specialised reception-process training, induction explanation, shadowing and periodic refresher training for nurses completing cell-sharing risk assessments.
Verbatim wording from the response “designed training specifically just for the reception process, which is a two day training. Which Antonio has been on recently.” Source location Response from Practice Plus Group
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 Prison authorities, rather than healthcare, are responsible for addressing staff training and prisoner guidance on managing seizures and first aid.
Verbatim wording from the response “Only number 1 above relates to healthcare, and therefore PPG, so we do not propose to respond to points 2 and 3, which no doubt will be addressed by the Prison.” Source location Response from Practice Plus Group
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 reception training, Early Days checks, clinical reviews and monitoring are considered sufficient to prevent inaccurate cell-sharing risk assessments.
Verbatim wording from the response “• Every patient has an Early Days passport as part of the Early Days process, which requires custodial managers and nurses to check off that items like the risk assessment form had been completed and completed to a sufficient standard. This requires a nurse to ensure that the risk assessment has been correctly completed, and sign off the passport.” Source location Response from Practice Plus Group
Open published response
20 Sep 2022 Gary McDonald · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 1 Failure to routinely follow up discrepancies between disclosed mental health history and community GP records View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Gary McDonald · 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
Gary McDonald was found deceased in his cell at HMP Hewell after spending nearly four months on remand awaiting trial; the inquest concluded that he died as a result of suicide. The principal concern was that, despite prison healthcare receiving records showing a history of depression and two previous overdoses, including one seven months earlier, there was no system to follow up discrepancies between a prisoner's disclosed mental health history and community GP records.
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; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely follow up discrepancies between disclosed mental health history and community GP records
Wider context from the report “5) I am concerned that there is currently no system in place at HMP Hewell to follow up with a prisoner any discrepancy between the mental health history which he has disclosed on arrival at the prison, and that revealed in his community GP records . Experience suggests that a prisoner with a recorded history of mental health issues, particularly one which includes a recent episode of attempted suicide or self-harm through overdose, may be at his most vulnerable during his first days and weeks at a prison, and having been reluctant to disclose such issues for any number of reasons ( e.g. fear, embarrassment ), may be reassured to be told that healthcare staff at the prison are aware of that history and can provide confidential support. In my view, without routine follow-up in such cases, there remains a significant risk that a prisoner’s recent significant history of suicide or self-harm may be overlooked in those important early days and weeks in prison , and that such prisoners will therefore be at an increased risk of further episodes of attempted suicide during that period.
” 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 Introduce Version 4 of the Early Days in Custody pathway and passport as a systematic healthcare induction checklist.
Verbatim wording from the response “Since the Inquest, the Head of Healthcare has consulted with other stakeholders within the team about the concern raised and have considered ways this concern can be alleviated. The healthcare team have introduced an updated version (V4) of the EDiC pathway and passport. This “passport” is a document that serves as a checklist to be completed by the healthcare induction team. By working through such a checklist in a systematic way, assurance is gained that all identified needs are being met for all patients, and to a consistent standard.” Source location Response Practice Plus Group
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 Implement Day 5 Senior Nurse management review and keyword searches of GP records for undisclosed suicide, self-harm or mental-health history.
Verbatim wording from the response “The key change between the previous version and Version 4 of this EDiC pathway is the timing of the Initial Management Review. It has been moved from Day 3 to Day 5 and now includes key word searches for suicide/self-harm references and will be undertaken after the GP2GP transition process has been completed. This key word search of the GP records has been implemented to identify any discrepancies in the information that the patient has disclosed during the reception screenings. If a patient was to deny a history of mental health illness during the reception screenings, the key word search would pick this history up in his GP records.” Source location Response Practice Plus Group
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 Implement GP2GP transfer of community GP records into HMP Hewell’s healthcare system.
Verbatim wording from the response “As part of a national NHS England rollout programme since April 2022, the Healthcare team and patients alike at HMP Hewell have benefitted from the introduction of the SystmOne upgrades commonly referred to as GP2GP. GP2GP is a process whereby the entire patient’s record from the community GP is transferred into HMP Hewell, where in effect the Healthcare team becomes the patient’s registered GP practice. The GP2GP functionality supports a number of benefits including:” Source location Response Practice Plus Group
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 Introduce follow-up discussions for identified discrepancies, including suicide and self-harm questions, mental-health referrals where indicated, and corresponding clinical records.
Verbatim wording from the response “At the point where the Day 5 management check has been completed, we have introduced new measures such as the key word search that address those specific concerns raised by the Coroner. These measures enable identification of previously undisclosed information and discrepancies about previous suicidal ideation and/or self-harm (irrespective of when). If any discrepancy is identified a member of the EDiC team (either a nurse or HCA) will return to meet the patient, informing him of our findings and then proceed to ask him 2 specific questions:” Source location Response Practice Plus Group
Open published response
Concerns raised 4 Lack of written instructions for conducting welfare checks View source Unclear allocation of task-list responsibilities during night-shift agency cover View source Gaps in communication of crucial substance-misuse and Naloxone information to Approved Premises View source Lack of auditing of task-list completion and welfare-check performance View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jamie Lee Bennett · 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
Jamie Lee Bennett, who had been abstinent from drugs and methadone for approximately eight months, was found unresponsive in his room at Norfolk Park Bail Hostel on 2 May 2020 and was pronounced deceased by paramedics. The report identified concerns about incomplete sharing of his substance-misuse and Naloxone information, reduced support after release, unclear responsibilities and inadequate training and auditing for welfare checks, and a delay in calling emergency services.
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; that does not assign responsibility.
PFD Monitor interpretation Lack of written instructions for conducting welfare checks
Wider context from the report “The evidence was unclear as to who will carry out actions on the task lists on a night shift when a Sodexo worker was replaced by agency staff. There is no audit process in place to ensure staff are carrying out tasks in accordance with the lists issued
There are no written instructions on how to conduct welfare checks . There is no audit process in place to ensure staff are conducting welfare checks appropriately
It is my opinion there is a risk that future deaths may occur unless there are:
• Clear, written instructions on how to conduct welfare checks
• Clarity around which member of staff will be responsible for which task list, particularly on a night shift when a Sodexo worker is replaced by agency staff
• An audit process put in place to ensure staff are carrying out tasks in accordance with the lists issued and in particular are conducting welfare checks 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 Practice Plus Group; that does not assign responsibility.
PFD Monitor interpretation Unclear allocation of task-list responsibilities during night-shift agency cover
Wider context from the report “The evidence was unclear as to who will carry out actions on the task lists on a night shift when a Sodexo worker was replaced by agency staff. There is no audit process in place to ensure staff are carrying out tasks in accordance with the lists issued
There are no written instructions on how to conduct welfare checks. There is no audit process in place to ensure staff are conducting welfare checks appropriately
It is my opinion there is a risk that future deaths may occur unless there are:
• Clear, written instructions on how to conduct welfare checks
• Clarity around which member of staff will be responsible for which task list, particularly on a night shift when a Sodexo worker is replaced by agency staff
• An audit process put in place to ensure staff are carrying out tasks in accordance with the lists issued and in particular are conducting welfare checks 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 Practice Plus Group; that does not assign responsibility.
PFD Monitor interpretation Gaps in communication of crucial substance-misuse and Naloxone information to Approved Premises
Wider context from the report “There were gaps in the information provided by HMP Moorlands to Norfolk Park Bail Hostel, in particular his history of substance misuse and that Jamie had refused Naloxone. The Court heard evidence that information sharing with third parties is in line with national guidelines, but also that there should have been another report by the offender management services that would have been more detailed and would have given this information to Norfolk Park . I do feel that if Norfolk Park Bail Hostel had that information, they would have been in a better position to support Jamie during those first crucial 48 hours and that may have reduced the risk of him using substances and dying
It is my view there should be a process by which crucial information about a patient is communicated to the Approved Premise , specifically substance misuse history, any substance misuse work, any detox or re-toxification processes undertaken, and whether the patient has accepted or refused Naloxone and any community drugs services referral. It is my view this will assist the Approved Premise to determine the level of support to be offered to a resident, especially those that are released on a Friday and will have limited support from anywhere other than an Approved Premise during the first 48 hours
It is my opinion there is a risk that future deaths may occur unless such a process is developed
” 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; that does not assign responsibility.
PFD Monitor interpretation Lack of auditing of task-list completion and welfare-check performance
Wider context from the report “The evidence was unclear as to who will carry out actions on the task lists on a night shift when a Sodexo worker was replaced by agency staff. There is no audit process in place to ensure staff are carrying out tasks in accordance with the lists issued
There are no written instructions on how to conduct welfare checks. There is no audit process in place to ensure staff are conducting welfare checks appropriately
It is my opinion there is a risk that future deaths may occur unless there are:
• Clear, written instructions on how to conduct welfare checks
• Clarity around which member of staff will be responsible for which task list, particularly on a night shift when a Sodexo worker is replaced by agency staff
• An audit process put in place to ensure staff are carrying out tasks in accordance with the lists issued and in particular are conducting welfare checks appropriately
” 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 Implement a tracked, consent-based process for quality-assured Approved Premises information reports, recording requests and completed reports on SystmOne.
Verbatim wording from the response “• A process has been immediately implemented for managing all Approved Premises information requests:
– Requests for patient information received are logged onto a spreadsheet for tracking the process.
– All information/medical report requests received are scanned onto the patient record on SystmOne.
– Consent to share information is signed by the patient and scanned onto the patient record (SystmOne).
– The Medical Record template is completed by a manager, quality assured and shared with the requesting provider.
– The completed report is scanned onto the patient record (SystmOne) providing an audit trail.” Source location Response from Practice Plus Group
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 Update the Naloxone refusal disclaimer and require refusals to be signed, scanned onto SystmOne and recorded in third-party medical reports.
Verbatim wording from the response “• Patients are provided with advice on discharge, where appropriate, about Naloxone. I understand this occurred in the case of Jamie Lee Bennett. However, in order for greater clarity and clinical safety, the disclaimer form for Naloxone has now been updated to make the risks of not accepting Naloxone clearer, please see Appendix B. When a” Source location Response from Practice Plus Group
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 Draft a detailed patient-release information template covering substance misuse, Naloxone, mental health and other relevant support needs.
Verbatim wording from the response “Following the Inquest, PPG Healthcare reflected on the type of information being requested and determined that more information should be shared. Therefore, Healthcare have drafted a more detailed template (attached for reference), which provides more specific information including, medical conditions, medication, COVID vaccinations, social services input, mental health concerns including history of self-harm, and specific equipment the patient may require, substance misuse involvement including SMS history, any current substance misuse work, any detox or re-toxification processes undertaken, whether the patient has been offered and trained for Naloxone and details of any community drugs service referrals that may have been made.” Source location Response from Practice Plus Group
Open published response
17 Sep 2021 Colin BLACKBURN · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 18 Failure to review the Care Map at ACCT Case Reviews View source Failure to hold an ACCT Case Review immediately before transfer View source Failure to hold an Initial ACCT Case Review within 24 hours of a concern View source Failure to carry out required ACCT observations View source Failure to conduct multidisciplinary ACCT Case Reviews View source Failure to hold an ACCT Case Review after a ligature incident View source Failure of ACCT Case Review participants to familiarise themselves with the ACCT document View source Failure to record triggers or warning signs on the ACCT inside cover View source Failure of ACCT Case Manager involvement after prisoner transfer View source Delays in holding scheduled ACCT Case Reviews View source Failure to document ligature incidents on the NOMIS record View source Failure to ensure prison staff understand their ACCT obligations View source Unavailability of timely urgent TAG referral handling at weekends View source Reliance on internal post for urgent TAG referrals View source Delays in reaching and opening urgent TAG referrals View source Delays in assigning an ACCT Case Manager View source Uncertainty among prison staff about the urgent weekend TAG referral pathway View source Failure to make timely entries on the ACCT Care Map View source See 15 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Colin BLACKBURN · 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
Colin Blackburn died at HMP Hewell on 6 July 2019 after spending 15 days on remand and having been found with a ligature around his neck on three prior occasions. Concerns included multiple accepted failings in the management of his ACCT suicide and self-harm risk, and uncertainty about the correct process for urgent mental-health referrals, particularly at weekends.
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; that does not assign responsibility.
PFD Monitor interpretation Failure to review the Care Map at ACCT Case Reviews
Wider context from the report “1) The Record of Inquest has recorded 14 separate failings in respect of Mr. Blackburn’s ACCT document and his risk of suicide/self-harm, all of which were accepted by H.M. Prison Service:
(a) that no Initial ACCT Case Review was held within 24 hours of the Concern;
(b) that no entries were made on the Care Map until 26.6.19;
(c) that no triggers or warning signs have been entered on the ACCT’s inside cover;
(d) that no ACCT Case Manager was assigned until 26.6.19;
(e) that no ACCT Case Manager had any effective involvement after Mr. Blackburn was transferred from the Inpatients unit to Houseblock 6 on 2.7.19;
(f) that ACCT Case Reviews were often not multi-disciplinary, with healthcare and mental healthcare sometimes not being invited to attend;
(g) that the Care Map was not reviewed at some ACCT Case Reviews ;
(h) that those conducting ACCT Case Reviews did not familiarise themselves sufficiently with the ACCT document beforehand;
(i) that on several occasions, over several hours, the level of observations required under the ACCT document were not carried out;
(j) that the first ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record;
(k) that no ACCT Case Review took place after the first ligature incident on 2.7.19;
(l) that there was no ACCT Case Review immediately before Mr. Blackburn’s transfer from the Inpatients unit to Houseblock 6 on the evening of 2.7.19, given particularly that Mr. Blackburn had been expecting a transfer to Houseblock 5;
(m) that the second ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record; and
(n) that the ACCT Case Review arranged for 3.7.19 did not in fact take place until 4.7.19.
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure to hold an ACCT Case Review immediately before transfer
Wider context from the report “1) The Record of Inquest has recorded 14 separate failings in respect of Mr. Blackburn’s ACCT document and his risk of suicide/self-harm, all of which were accepted by H.M. Prison Service:
(a) that no Initial ACCT Case Review was held within 24 hours of the Concern;
(b) that no entries were made on the Care Map until 26.6.19;
(c) that no triggers or warning signs have been entered on the ACCT’s inside cover;
(d) that no ACCT Case Manager was assigned until 26.6.19;
(e) that no ACCT Case Manager had any effective involvement after Mr. Blackburn was transferred from the Inpatients unit to Houseblock 6 on 2.7.19;
(f) that ACCT Case Reviews were often not multi-disciplinary, with healthcare and mental healthcare sometimes not being invited to attend;
(g) that the Care Map was not reviewed at some ACCT Case Reviews;
(h) that those conducting ACCT Case Reviews did not familiarise themselves sufficiently with the ACCT document beforehand;
(i) that on several occasions, over several hours, the level of observations required under the ACCT document were not carried out;
(j) that the first ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record;
(k) that no ACCT Case Review took place after the first ligature incident on 2.7.19;
(l) that there was no ACCT Case Review immediately before Mr. Blackburn’s transfer from the Inpatients unit to Houseblock 6 on the evening of 2.7.19, given particularly that Mr. Blackburn had been expecting a transfer to Houseblock 5;
(m) that the second ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record; and
(n) that the ACCT Case Review arranged for 3.7.19 did not in fact take place until 4.7.19.
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure to hold an Initial ACCT Case Review within 24 hours of a concern
Wider context from the report “1) The Record of Inquest has recorded 14 separate failings in respect of Mr. Blackburn’s ACCT document and his risk of suicide/self-harm, all of which were accepted by H.M. Prison Service:
(a) that no Initial ACCT Case Review was held within 24 hours of the Concern ;
(b) that no entries were made on the Care Map until 26.6.19;
(c) that no triggers or warning signs have been entered on the ACCT’s inside cover;
(d) that no ACCT Case Manager was assigned until 26.6.19;
(e) that no ACCT Case Manager had any effective involvement after Mr. Blackburn was transferred from the Inpatients unit to Houseblock 6 on 2.7.19;
(f) that ACCT Case Reviews were often not multi-disciplinary, with healthcare and mental healthcare sometimes not being invited to attend;
(g) that the Care Map was not reviewed at some ACCT Case Reviews;
(h) that those conducting ACCT Case Reviews did not familiarise themselves sufficiently with the ACCT document beforehand;
(i) that on several occasions, over several hours, the level of observations required under the ACCT document were not carried out;
(j) that the first ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record;
(k) that no ACCT Case Review took place after the first ligature incident on 2.7.19;
(l) that there was no ACCT Case Review immediately before Mr. Blackburn’s transfer from the Inpatients unit to Houseblock 6 on the evening of 2.7.19, given particularly that Mr. Blackburn had been expecting a transfer to Houseblock 5;
(m) that the second ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record; and
(n) that the ACCT Case Review arranged for 3.7.19 did not in fact take place until 4.7.19.
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out required ACCT observations
Wider context from the report “1) The Record of Inquest has recorded 14 separate failings in respect of Mr. Blackburn’s ACCT document and his risk of suicide/self-harm, all of which were accepted by H.M. Prison Service:
(a) that no Initial ACCT Case Review was held within 24 hours of the Concern;
(b) that no entries were made on the Care Map until 26.6.19;
(c) that no triggers or warning signs have been entered on the ACCT’s inside cover;
(d) that no ACCT Case Manager was assigned until 26.6.19;
(e) that no ACCT Case Manager had any effective involvement after Mr. Blackburn was transferred from the Inpatients unit to Houseblock 6 on 2.7.19;
(f) that ACCT Case Reviews were often not multi-disciplinary, with healthcare and mental healthcare sometimes not being invited to attend;
(g) that the Care Map was not reviewed at some ACCT Case Reviews;
(h) that those conducting ACCT Case Reviews did not familiarise themselves sufficiently with the ACCT document beforehand;
(i) that on several occasions, over several hours, the level of observations required under the ACCT document were not carried out ;
(j) that the first ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record;
(k) that no ACCT Case Review took place after the first ligature incident on 2.7.19;
(l) that there was no ACCT Case Review immediately before Mr. Blackburn’s transfer from the Inpatients unit to Houseblock 6 on the evening of 2.7.19, given particularly that Mr. Blackburn had been expecting a transfer to Houseblock 5;
(m) that the second ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record; and
(n) that the ACCT Case Review arranged for 3.7.19 did not in fact take place until 4.7.19.
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct multidisciplinary ACCT Case Reviews
Wider context from the report “1) The Record of Inquest has recorded 14 separate failings in respect of Mr. Blackburn’s ACCT document and his risk of suicide/self-harm, all of which were accepted by H.M. Prison Service:
(a) that no Initial ACCT Case Review was held within 24 hours of the Concern;
(b) that no entries were made on the Care Map until 26.6.19;
(c) that no triggers or warning signs have been entered on the ACCT’s inside cover;
(d) that no ACCT Case Manager was assigned until 26.6.19;
(e) that no ACCT Case Manager had any effective involvement after Mr. Blackburn was transferred from the Inpatients unit to Houseblock 6 on 2.7.19;
(f) that ACCT Case Reviews were often not multi-disciplinary , with healthcare and mental healthcare sometimes not being invited to attend ;
(g) that the Care Map was not reviewed at some ACCT Case Reviews;
(h) that those conducting ACCT Case Reviews did not familiarise themselves sufficiently with the ACCT document beforehand;
(i) that on several occasions, over several hours, the level of observations required under the ACCT document were not carried out;
(j) that the first ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record;
(k) that no ACCT Case Review took place after the first ligature incident on 2.7.19;
(l) that there was no ACCT Case Review immediately before Mr. Blackburn’s transfer from the Inpatients unit to Houseblock 6 on the evening of 2.7.19, given particularly that Mr. Blackburn had been expecting a transfer to Houseblock 5;
(m) that the second ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record; and
(n) that the ACCT Case Review arranged for 3.7.19 did not in fact take place until 4.7.19.
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure to hold an ACCT Case Review after a ligature incident
Wider context from the report “1) The Record of Inquest has recorded 14 separate failings in respect of Mr. Blackburn’s ACCT document and his risk of suicide/self-harm, all of which were accepted by H.M. Prison Service:
(a) that no Initial ACCT Case Review was held within 24 hours of the Concern;
(b) that no entries were made on the Care Map until 26.6.19;
(c) that no triggers or warning signs have been entered on the ACCT’s inside cover;
(d) that no ACCT Case Manager was assigned until 26.6.19;
(e) that no ACCT Case Manager had any effective involvement after Mr. Blackburn was transferred from the Inpatients unit to Houseblock 6 on 2.7.19;
(f) that ACCT Case Reviews were often not multi-disciplinary, with healthcare and mental healthcare sometimes not being invited to attend;
(g) that the Care Map was not reviewed at some ACCT Case Reviews;
(h) that those conducting ACCT Case Reviews did not familiarise themselves sufficiently with the ACCT document beforehand;
(i) that on several occasions, over several hours, the level of observations required under the ACCT document were not carried out;
(j) that the first ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record;
(k) that no ACCT Case Review took place after the first ligature incident on 2.7.19 ;
(l) that there was no ACCT Case Review immediately before Mr. Blackburn’s transfer from the Inpatients unit to Houseblock 6 on the evening of 2.7.19, given particularly that Mr. Blackburn had been expecting a transfer to Houseblock 5;
(m) that the second ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record; and
(n) that the ACCT Case Review arranged for 3.7.19 did not in fact take place until 4.7.19.
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure of ACCT Case Review participants to familiarise themselves with the ACCT document
Wider context from the report “1) The Record of Inquest has recorded 14 separate failings in respect of Mr. Blackburn’s ACCT document and his risk of suicide/self-harm, all of which were accepted by H.M. Prison Service:
(a) that no Initial ACCT Case Review was held within 24 hours of the Concern;
(b) that no entries were made on the Care Map until 26.6.19;
(c) that no triggers or warning signs have been entered on the ACCT’s inside cover;
(d) that no ACCT Case Manager was assigned until 26.6.19;
(e) that no ACCT Case Manager had any effective involvement after Mr. Blackburn was transferred from the Inpatients unit to Houseblock 6 on 2.7.19;
(f) that ACCT Case Reviews were often not multi-disciplinary, with healthcare and mental healthcare sometimes not being invited to attend;
(g) that the Care Map was not reviewed at some ACCT Case Reviews;
(h) that those conducting ACCT Case Reviews did not familiarise themselves sufficiently with the ACCT document beforehand ;
(i) that on several occasions, over several hours, the level of observations required under the ACCT document were not carried out;
(j) that the first ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record;
(k) that no ACCT Case Review took place after the first ligature incident on 2.7.19;
(l) that there was no ACCT Case Review immediately before Mr. Blackburn’s transfer from the Inpatients unit to Houseblock 6 on the evening of 2.7.19, given particularly that Mr. Blackburn had been expecting a transfer to Houseblock 5;
(m) that the second ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record; and
(n) that the ACCT Case Review arranged for 3.7.19 did not in fact take place until 4.7.19.
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure to record triggers or warning signs on the ACCT inside cover
Wider context from the report “1) The Record of Inquest has recorded 14 separate failings in respect of Mr. Blackburn’s ACCT document and his risk of suicide/self-harm, all of which were accepted by H.M. Prison Service:
(a) that no Initial ACCT Case Review was held within 24 hours of the Concern;
(b) that no entries were made on the Care Map until 26.6.19;
(c) that no triggers or warning signs have been entered on the ACCT’s inside cover ;
(d) that no ACCT Case Manager was assigned until 26.6.19;
(e) that no ACCT Case Manager had any effective involvement after Mr. Blackburn was transferred from the Inpatients unit to Houseblock 6 on 2.7.19;
(f) that ACCT Case Reviews were often not multi-disciplinary, with healthcare and mental healthcare sometimes not being invited to attend;
(g) that the Care Map was not reviewed at some ACCT Case Reviews;
(h) that those conducting ACCT Case Reviews did not familiarise themselves sufficiently with the ACCT document beforehand;
(i) that on several occasions, over several hours, the level of observations required under the ACCT document were not carried out;
(j) that the first ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record;
(k) that no ACCT Case Review took place after the first ligature incident on 2.7.19;
(l) that there was no ACCT Case Review immediately before Mr. Blackburn’s transfer from the Inpatients unit to Houseblock 6 on the evening of 2.7.19, given particularly that Mr. Blackburn had been expecting a transfer to Houseblock 5;
(m) that the second ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record; and
(n) that the ACCT Case Review arranged for 3.7.19 did not in fact take place until 4.7.19.
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure of ACCT Case Manager involvement after prisoner transfer
Wider context from the report “1) The Record of Inquest has recorded 14 separate failings in respect of Mr. Blackburn’s ACCT document and his risk of suicide/self-harm, all of which were accepted by H.M. Prison Service:
(a) that no Initial ACCT Case Review was held within 24 hours of the Concern;
(b) that no entries were made on the Care Map until 26.6.19;
(c) that no triggers or warning signs have been entered on the ACCT’s inside cover;
(d) that no ACCT Case Manager was assigned until 26.6.19;
(e) that no ACCT Case Manager had any effective involvement after Mr. Blackburn was transferred from the Inpatients unit to Houseblock 6 on 2.7.19 ;
(f) that ACCT Case Reviews were often not multi-disciplinary, with healthcare and mental healthcare sometimes not being invited to attend;
(g) that the Care Map was not reviewed at some ACCT Case Reviews;
(h) that those conducting ACCT Case Reviews did not familiarise themselves sufficiently with the ACCT document beforehand;
(i) that on several occasions, over several hours, the level of observations required under the ACCT document were not carried out;
(j) that the first ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record;
(k) that no ACCT Case Review took place after the first ligature incident on 2.7.19;
(l) that there was no ACCT Case Review immediately before Mr. Blackburn’s transfer from the Inpatients unit to Houseblock 6 on the evening of 2.7.19, given particularly that Mr. Blackburn had been expecting a transfer to Houseblock 5;
(m) that the second ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record; and
(n) that the ACCT Case Review arranged for 3.7.19 did not in fact take place until 4.7.19.
” 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; that does not assign responsibility.
PFD Monitor interpretation Delays in holding scheduled ACCT Case Reviews
Wider context from the report “1) The Record of Inquest has recorded 14 separate failings in respect of Mr. Blackburn’s ACCT document and his risk of suicide/self-harm, all of which were accepted by H.M. Prison Service:
(a) that no Initial ACCT Case Review was held within 24 hours of the Concern;
(b) that no entries were made on the Care Map until 26.6.19;
(c) that no triggers or warning signs have been entered on the ACCT’s inside cover;
(d) that no ACCT Case Manager was assigned until 26.6.19;
(e) that no ACCT Case Manager had any effective involvement after Mr. Blackburn was transferred from the Inpatients unit to Houseblock 6 on 2.7.19;
(f) that ACCT Case Reviews were often not multi-disciplinary, with healthcare and mental healthcare sometimes not being invited to attend;
(g) that the Care Map was not reviewed at some ACCT Case Reviews;
(h) that those conducting ACCT Case Reviews did not familiarise themselves sufficiently with the ACCT document beforehand;
(i) that on several occasions, over several hours, the level of observations required under the ACCT document were not carried out;
(j) that the first ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record;
(k) that no ACCT Case Review took place after the first ligature incident on 2.7.19;
(l) that there was no ACCT Case Review immediately before Mr. Blackburn’s transfer from the Inpatients unit to Houseblock 6 on the evening of 2.7.19, given particularly that Mr. Blackburn had been expecting a transfer to Houseblock 5;
(m) that the second ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record; and
(n) that the ACCT Case Review arranged for 3.7.19 did not in fact take place until 4.7.19 .
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure to document ligature incidents on the NOMIS record
Wider context from the report “1) The Record of Inquest has recorded 14 separate failings in respect of Mr. Blackburn’s ACCT document and his risk of suicide/self-harm, all of which were accepted by H.M. Prison Service:
(a) that no Initial ACCT Case Review was held within 24 hours of the Concern;
(b) that no entries were made on the Care Map until 26.6.19;
(c) that no triggers or warning signs have been entered on the ACCT’s inside cover;
(d) that no ACCT Case Manager was assigned until 26.6.19;
(e) that no ACCT Case Manager had any effective involvement after Mr. Blackburn was transferred from the Inpatients unit to Houseblock 6 on 2.7.19;
(f) that ACCT Case Reviews were often not multi-disciplinary, with healthcare and mental healthcare sometimes not being invited to attend;
(g) that the Care Map was not reviewed at some ACCT Case Reviews;
(h) that those conducting ACCT Case Reviews did not familiarise themselves sufficiently with the ACCT document beforehand;
(i) that on several occasions, over several hours, the level of observations required under the ACCT document were not carried out;
(j) that the first ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record ;
(k) that no ACCT Case Review took place after the first ligature incident on 2.7.19;
(l) that there was no ACCT Case Review immediately before Mr. Blackburn’s transfer from the Inpatients unit to Houseblock 6 on the evening of 2.7.19, given particularly that Mr. Blackburn had been expecting a transfer to Houseblock 5;
(m) that the second ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record; and
(n) that the ACCT Case Review arranged for 3.7.19 did not in fact take place until 4.7.19.
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure prison staff understand their ACCT obligations
Wider context from the report “I am not satisfied that sufficient action has yet been taken to ensure that all members of prison staff understand their obligations in respect of prisoners who are subject to the ACCT process. This is because:
(i) there is no evidence yet that the changes described above have led to a change in how prison staff deal with ACCT documents ; and
(ii) I heard evidence during the inquest from a number of senior officers who, even now, found it difficult to comprehend that their involvement with Mr. Blackburn and his ACCT document fell short of an acceptable standard .
” 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; that does not assign responsibility.
PFD Monitor interpretation Unavailability of timely urgent TAG referral handling at weekends
Wider context from the report “2) On 4.7.19, a prison officer, who had concerns about a significant deterioration in Mr. Blackburn’s mental state, submitted a paper TAG referral to the Mental Health team at the prison via the internal post. There was a delay in that referral reaching the Mental Team, with the result that it was not opened until after Mr. Blackburn’s death. Had it been opened sooner, the court was told that an urgent mental health assessment would have been carried out.
I heard evidence from the Head of Healthcare at the prison that urgent TAG referrals currently are made by email, phone or on paper via internal post. If made late on a Friday or over a weekend, there was no guarantee that the mental health team would pick up the referral until after the weekend ; instead, the referral should be made to a member of the healthcare team on duty that weekend, who would then phone Practice Plus Group’s regional on-call manager.
I received no assurance that prison staff wanting to make an urgent TAG referral over a weekend knew that this was the process to follow, and heard that there is currently no divert service in place, so that if a member of staff tries to make an urgent referral by phone or email over the weekend, they are redirected to the correct pathway.
The paper referral system, which relies upon the internal post at the prison, is still in place although, I am told, it can be stopped.
In my view, there remains uncertainty amongst staff at the prison about the right way to make an urgent TAG referral to the mental health team, particularly at weekends. There is a risk therefore that a prisoner whose mental health deteriorates significantly during a weekend may not be properly assessed in time for action to be taken to address any risk of suicide or self-harm which he may present.
” 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; that does not assign responsibility.
PFD Monitor interpretation Reliance on internal post for urgent TAG referrals
Wider context from the report “2) On 4.7.19, a prison officer, who had concerns about a significant deterioration in Mr. Blackburn’s mental state, submitted a paper TAG referral to the Mental Health team at the prison via the internal post. There was a delay in that referral reaching the Mental Team, with the result that it was not opened until after Mr. Blackburn’s death. Had it been opened sooner, the court was told that an urgent mental health assessment would have been carried out.
I heard evidence from the Head of Healthcare at the prison that urgent TAG referrals currently are made by email, phone or on paper via internal post. If made late on a Friday or over a weekend, there was no guarantee that the mental health team would pick up the referral until after the weekend; instead, the referral should be made to a member of the healthcare team on duty that weekend, who would then phone Practice Plus Group’s regional on-call manager.
I received no assurance that prison staff wanting to make an urgent TAG referral over a weekend knew that this was the process to follow, and heard that there is currently no divert service in place, so that if a member of staff tries to make an urgent referral by phone or email over the weekend, they are redirected to the correct pathway.
The paper referral system, which relies upon the internal post at the prison, is still in place although, I am told, it can be stopped.
In my view, there remains uncertainty amongst staff at the prison about the right way to make an urgent TAG referral to the mental health team, particularly at weekends. There is a risk therefore that a prisoner whose mental health deteriorates significantly during a weekend may not be properly assessed in time for action to be taken to address any risk of suicide or self-harm which he may present.
” 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; that does not assign responsibility.
PFD Monitor interpretation Delays in reaching and opening urgent TAG referrals
Wider context from the report “2) On 4.7.19, a prison officer, who had concerns about a significant deterioration in Mr. Blackburn’s mental state, submitted a paper TAG referral to the Mental Health team at the prison via the internal post. There was a delay in that referral reaching the Mental Team , with the result that it was not opened until after Mr. Blackburn’s death . Had it been opened sooner, the court was told that an urgent mental health assessment would have been carried out.
I heard evidence from the Head of Healthcare at the prison that urgent TAG referrals currently are made by email, phone or on paper via internal post. If made late on a Friday or over a weekend, there was no guarantee that the mental health team would pick up the referral until after the weekend; instead, the referral should be made to a member of the healthcare team on duty that weekend, who would then phone Practice Plus Group’s regional on-call manager.
I received no assurance that prison staff wanting to make an urgent TAG referral over a weekend knew that this was the process to follow, and heard that there is currently no divert service in place, so that if a member of staff tries to make an urgent referral by phone or email over the weekend, they are redirected to the correct pathway.
The paper referral system, which relies upon the internal post at the prison, is still in place although, I am told, it can be stopped.
In my view, there remains uncertainty amongst staff at the prison about the right way to make an urgent TAG referral to the mental health team, particularly at weekends. There is a risk therefore that a prisoner whose mental health deteriorates significantly during a weekend may not be properly assessed in time for action to be taken to address any risk of suicide or self-harm which he may present.
” 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; that does not assign responsibility.
PFD Monitor interpretation Delays in assigning an ACCT Case Manager
Wider context from the report “1) The Record of Inquest has recorded 14 separate failings in respect of Mr. Blackburn’s ACCT document and his risk of suicide/self-harm, all of which were accepted by H.M. Prison Service:
(a) that no Initial ACCT Case Review was held within 24 hours of the Concern;
(b) that no entries were made on the Care Map until 26.6.19;
(c) that no triggers or warning signs have been entered on the ACCT’s inside cover;
(d) that no ACCT Case Manager was assigned until 26.6.19 ;
(e) that no ACCT Case Manager had any effective involvement after Mr. Blackburn was transferred from the Inpatients unit to Houseblock 6 on 2.7.19;
(f) that ACCT Case Reviews were often not multi-disciplinary, with healthcare and mental healthcare sometimes not being invited to attend;
(g) that the Care Map was not reviewed at some ACCT Case Reviews;
(h) that those conducting ACCT Case Reviews did not familiarise themselves sufficiently with the ACCT document beforehand;
(i) that on several occasions, over several hours, the level of observations required under the ACCT document were not carried out;
(j) that the first ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record;
(k) that no ACCT Case Review took place after the first ligature incident on 2.7.19;
(l) that there was no ACCT Case Review immediately before Mr. Blackburn’s transfer from the Inpatients unit to Houseblock 6 on the evening of 2.7.19, given particularly that Mr. Blackburn had been expecting a transfer to Houseblock 5;
(m) that the second ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record; and
(n) that the ACCT Case Review arranged for 3.7.19 did not in fact take place until 4.7.19.
” 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; that does not assign responsibility.
PFD Monitor interpretation Uncertainty among prison staff about the urgent weekend TAG referral pathway
Wider context from the report “2) On 4.7.19, a prison officer, who had concerns about a significant deterioration in Mr. Blackburn’s mental state, submitted a paper TAG referral to the Mental Health team at the prison via the internal post. There was a delay in that referral reaching the Mental Team, with the result that it was not opened until after Mr. Blackburn’s death. Had it been opened sooner, the court was told that an urgent mental health assessment would have been carried out.
I heard evidence from the Head of Healthcare at the prison that urgent TAG referrals currently are made by email, phone or on paper via internal post. If made late on a Friday or over a weekend, there was no guarantee that the mental health team would pick up the referral until after the weekend; instead, the referral should be made to a member of the healthcare team on duty that weekend, who would then phone Practice Plus Group’s regional on-call manager.
I received no assurance that prison staff wanting to make an urgent TAG referral over a weekend knew that this was the process to follow , and heard that there is currently no divert service in place , so that if a member of staff tries to make an urgent referral by phone or email over the weekend, they are redirected to the correct pathway.
The paper referral system, which relies upon the internal post at the prison, is still in place although, I am told, it can be stopped.
In my view, there remains uncertainty amongst staff at the prison about the right way to make an urgent TAG referral to the mental health team, particularly at weekends . There is a risk therefore that a prisoner whose mental health deteriorates significantly during a weekend may not be properly assessed in time for action to be taken to address any risk of suicide or self-harm which he may present.
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure to make timely entries on the ACCT Care Map
Wider context from the report “1) The Record of Inquest has recorded 14 separate failings in respect of Mr. Blackburn’s ACCT document and his risk of suicide/self-harm, all of which were accepted by H.M. Prison Service:
(a) that no Initial ACCT Case Review was held within 24 hours of the Concern;
(b) that no entries were made on the Care Map until 26.6.19 ;
(c) that no triggers or warning signs have been entered on the ACCT’s inside cover;
(d) that no ACCT Case Manager was assigned until 26.6.19;
(e) that no ACCT Case Manager had any effective involvement after Mr. Blackburn was transferred from the Inpatients unit to Houseblock 6 on 2.7.19;
(f) that ACCT Case Reviews were often not multi-disciplinary, with healthcare and mental healthcare sometimes not being invited to attend;
(g) that the Care Map was not reviewed at some ACCT Case Reviews;
(h) that those conducting ACCT Case Reviews did not familiarise themselves sufficiently with the ACCT document beforehand;
(i) that on several occasions, over several hours, the level of observations required under the ACCT document were not carried out;
(j) that the first ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record;
(k) that no ACCT Case Review took place after the first ligature incident on 2.7.19;
(l) that there was no ACCT Case Review immediately before Mr. Blackburn’s transfer from the Inpatients unit to Houseblock 6 on the evening of 2.7.19, given particularly that Mr. Blackburn had been expecting a transfer to Houseblock 5;
(m) that the second ligature incident on 2.7.19 was not documented on Mr. Blackburn’s NOMIS record; and
(n) that the ACCT Case Review arranged for 3.7.19 did not in fact take place until 4.7.19.
” 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 Provide and operate an answerphone for urgent referrals when staff lack immediate computer access, with messages logged and forwarded by the administration team.
Verbatim wording from the response “7. As an alternative to the electronic referral route for such times when a prison staff member may not have immediate access to a computer, an answer phone has been purchased for the mental health team and has been in utilisation since 13th October 2021. Whilst those incoming messages will be recorded, the voicemail auto-message will be the same as the generic email out of office response (as above). The email signatures of all members of staff within the mental health team display the generic phone number, which reaches this phone (which now carries a voicemail facility). This ensures that irrespective of whether a member of the mental health team is away from his/her desk, the incoming call will be received by the admin team, for logging and forwarding as appropriate.” Source location Response from Practice Plus Group
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 End paper TAG referrals and transition referrals to the electronic process.
Verbatim wording from the response “1. The end date for the acceptance of paper referrals is 31st October 2021. From 1st November 2021, paper TAGs (Threshold Assessment Grid)¹ will cease to be an option for referrals to the mental health team. The reason as to why this process could not immediately be stopped is to allow for the transition from paper referrals (and the communication thereof) without incurring the additional risk of patients’ referrals being missed. In this interim period paper TAGs are being accepted by the mental health team, however, the individual who sends the TAG referral is then being asked to provide their email address to which the electronic TAG is being sent along with guidance as to how to use it, for their future reference, beyond 31st October 2021.” Source location Response from Practice Plus Group
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 Display posters explaining electronic and out-of-hours TAG referral pathways throughout the prison and disseminate the notice to prison staff by global email.
Verbatim wording from the response “2. As part of this transition, posters have also been created to explain the process of making electronic TAG referrals. These are now on display (laminated, A3 size) throughout the prison. I enclose a copy of the poster with this response for your information. This work has been undertaken in conjunction with the Prison’s Health & wellbeing Governor.” Source location Response from Practice Plus Group
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 Add urgent mental health referral routes, service hours and escalation contact details to mental health team email signatures.
Verbatim wording from the response “5. All members of the mental health team have now added the following text to their email signatures:-” Source location 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 Specific operational queries about mental health provision at HMP Hewell should be directed to Midlands Partnership NHS Foundation Trust.
Verbatim wording from the response “Practice Plus Group is the main provider of healthcare services at HMP Hewell. There is a sub-contracting arrangement in place with Midlands Partnership NHS Foundation Trust (‘MPFT’) in respect of the provision of mental health services. The Regulation 28 report was not addressed to MPFT although it has had sight of your report. This response has been prepared with the input of members of staff working for MPFT at HMP Hewell. In the event that there are any further specific operational queries relating to the mental health provision at HMP Hewell, I respectfully request that such queries be directed to MPFT.” Source location 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 The paper referral process could not immediately be stopped because transition without communication risked referrals being missed.
Verbatim wording from the response “1. The end date for the acceptance of paper referrals is 31st October 2021. From 1st November 2021, paper TAGs (Threshold Assessment Grid)¹ will cease to be an option for referrals to the mental health team. The reason as to why this process could not immediately be stopped is to allow for the transition from paper referrals (and the communication thereof) without incurring the additional risk of patients’ referrals being missed. In this interim period paper TAGs are being accepted by the mental health team, however, the individual who sends the TAG referral is then being asked to provide their email address to which the electronic TAG is being sent along with guidance as to how to use it, for their future reference, beyond 31st October 2021.” Source location Response from Practice Plus Group
Open published response
Concerns raised 3 Confusing definitions of post-death signs in CPR decision-making guidance View source Insufficient nursing staff understanding of identifying hypostasis and rigor mortis View source Insufficient life support training coverage of hypostasis and rigor mortis identification View source
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
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
Darren Adams was transferred between prisons and, within 24 hours of arrival, experienced a deterioration in his mental health. He was found ligatured in his cell on 12 November 2017 and was declared dead at hospital on 13 November 2017; the inquest concluded that he died by suicide. Concerns included nursing staff misdiagnosing hypostasis and rigor mortis, insufficient training in identifying these conditions, and potentially confusing definitions in CPR guidance.
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; that does not assign responsibility.
PFD Monitor interpretation Confusing definitions of post-death signs in CPR decision-making guidance
Wider context from the report “4. It was seen during the evidence that definitions in Annex A of the document “Guidance to support the decision-making process of when not to perform Cardiopulmonary Resuscitation in prisons and immigration removal centre (IRC)” could be confusing , for example the word “mottling” was interpreted by different people in different ways (both lay and medical) .
” 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; that does not assign responsibility.
PFD Monitor interpretation Insufficient nursing staff understanding of identifying hypostasis and rigor mortis
Wider context from the report “1. The Nursing Staff misdiagnosed hypostasis. It was apparent in evidence that they did not have a sufficient understanding of the process and how to identify it.
2. The Nursing Staff misdiagnosed rigor mortis. It was apparent in evidence that they did not have a sufficient understanding of the process and how to identify 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 Practice Plus Group; that does not assign responsibility.
PFD Monitor interpretation Insufficient life support training coverage of hypostasis and rigor mortis identification
Wider context from the report “3. Management of the nurses accepted in evidence that more focus on the identification of those conditions should have been covered in better depth during the nurse’s life support training .
” 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 Introduce mandatory ILS teaching on hypostasis, lividity and rigor mortis, including mandatory decision-making scenarios, through the revised curriculum from July 2021.
Verbatim wording from the response “• Practice Plus Group mandates annual Intermediate Life Support Training (ILS) for all clinical staff in recognition of their critical role in providing pre hospital life support. Non clinical staff are trained in Basic Life Support and agency staff are required to have undertaken ILS training and can access the training provided by Practice Plus Group. The curriculum for PPG’s ILS training has been adapted by our training provider to include prison specific scenarios. The training is delivered by Resuscitation Council accredited trainers. Following this request, the training provider has spoken to staff who have been involved in resuscitation decision-making scenarios to hear their experiences and understand the issues that are faced, including the challenges of diagnosing hypostasis. Our training provider has amended the content of the previously provided ILS course to include:” Source location Response from Practice Plus Group
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 Teach clinical staff how to diagnose death.
Verbatim wording from the response “Response: This guidance was issued by the National Offender Management Service (NOMS), Royal College of Nursing (RCN) and the Royal College of General Practitioners (RCGP) in March 2016. Therefore, the terminology sits outside the control of Practice Plus Group. For Practice Plus Group we will:” Source location Response from Practice Plus Group
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 Teach staff the practical meaning of terminology used in Resuscitation Council UK guidance.
Verbatim wording from the response “Response: This guidance was issued by the National Offender Management Service (NOMS), Royal College of Nursing (RCN) and the Royal College of General Practitioners (RCGP) in March 2016. Therefore, the terminology sits outside the control of Practice Plus Group. For Practice Plus Group we will:” Source location Response from Practice Plus Group
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Incorporate revisions to the relevant guidance into Practice Plus Group training.
Verbatim wording from the response “Response: This guidance was issued by the National Offender Management Service (NOMS), Royal College of Nursing (RCN) and the Royal College of General Practitioners (RCGP) in March 2016. Therefore, the terminology sits outside the control of Practice Plus Group. For Practice Plus Group we will:” Source location 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 Changing the terminology in the prison CPR guidance is outside the respondent’s control.
Verbatim wording from the response “Response: This guidance was issued by the National Offender Management Service (NOMS), Royal College of Nursing (RCN) and the Royal College of General Practitioners (RCGP) in March 2016. Therefore, the terminology sits outside the control of Practice Plus Group. For Practice Plus Group we will:” Source location 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