24 Mar 2026 Ronald William MEIKLE · Prevention of Future Deaths report Milton Keynes
View report summary
Concerns raised 16 Weak supervision and staff-prisoner engagement View source Failure to maintain a clear and current drug under the influence policy View source Delays or insufficiency in psychiatric assessment and proactive mental health review View source Failure to recognise suspected synthetic cannabinoid intoxication promptly during collapse response View source Insufficient staffing capacity View source Restricted prison regimes View source Insufficiently robust identification and management of prisoners remaining behind their door because of vulnerability View source Inadequate welfare observations View source Inconsistent identification, assessment, monitoring and response to prisoners under the influence of illicit substances View source Failure to escalate prisoners with cumulative vulnerability indicators into safer custody procedures View source Availability of illicit substances in custody View source Failure to reliably consolidate and share relevant prisoner risk information View source Failure to maintain unobstructed observation panels for effective visual welfare checks View source Delays in supplying material information relevant to death investigations and future-death prevention View source Failure to implement sufficient and sustained remedial action on identified prison safety concerns View source Failure to recognise IPP status as a material vulnerability requiring structured support and review View source See 13 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Ronald William MEIKLE · 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
Ronald William Meikle was found unresponsive in his single-occupancy cell at HMP Woodhill on 30 April 2024 and was pronounced dead at 09:43. The report identified concerns about illicit substances, inconsistent responses to suspected intoxication, fragmented information-sharing, inadequate welfare observations, management of self-isolation and vulnerability, absence of ACCT proceedings, mental-health input, emergency response, staffing, and recurring systemic problems at the prison.
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 Prisons and Probation Ombudsman; that does not assign responsibility.
PFD Monitor interpretation Weak supervision and staff-prisoner engagement
Wider context from the report “Concern 10: Staffing, supervision and regime limitations
The evidence before the court, including wider inspection material, raised concern that staffing pressures, weak supervision, poor staff-prisoner engagement , restricted regimes, and inadequate welfare observations may materially increase the risk of undetected drug use, delayed discovery of collapsed prisoners and failure to identify vulnerable men in need of intervention.
” 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 Prisons and Probation Ombudsman; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain a clear and current drug under the influence policy
Wider context from the report “Concern 2: Failure consistently to identify, record and respond to prisoners under the influence
The evidence showed concerns about the consistency with which prisoners suspected or found to be under the influence of illicit substances were identified, clinically assessed, monitored, referred to substance misuse services, and managed under prison and healthcare processes. There was evidence that episodes of apparent intoxication were not always met with a consistent healthcare response or documented follow-up. The head of service had an understanding of the drug under the influence policy that was starkly different to the written document . There had been multiple updates of the drug policy which were difficult to identify as to when the policy was updated / revised . I am concerned that prisoners at acute risk of overdose or deterioration may therefore not receive timely intervention.
” 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 Prisons and Probation Ombudsman; that does not assign responsibility.
PFD Monitor interpretation Delays or insufficiency in psychiatric assessment and proactive mental health review
Wider context from the report “Concern 8: Delay or insufficiency in mental health and psychiatric input
The evidence raised concern that prisoners with known vulnerabilities, substance misuse history and symptoms of deteriorating mental health may not always receive timely psychiatric assessment or sufficiently proactive mental health review . Delays in specialist assessment can increase the risk of unmanaged distress, relapse to substance use and death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Prisons and Probation Ombudsman; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise suspected synthetic cannabinoid intoxication promptly during collapse response
Wider context from the report “Concern 9: Emergency response to suspected synthetic cannabinoid collapse
The evidence raised concern about whether staff responding to collapse were adequately trained and equipped to consider synthetic cannabinoid intoxication promptly as a possible cause . Synthetic cannabinoid use can cause rapid deterioration and death. If staff do not recognise that possibility, there is a risk of delay in appropriate emergency action, clinical escalation and treatment .
” 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 Prisons and Probation Ombudsman; that does not assign responsibility.
PFD Monitor interpretation Insufficient staffing capacity
Wider context from the report “Concern 10: Staffing, supervision and regime limitations
The evidence before the court, including wider inspection material, raised concern that staffing pressures , weak supervision, poor staff-prisoner engagement, restricted regimes, and inadequate welfare observations may materially increase the risk of undetected drug use, delayed discovery of collapsed prisoners and failure to identify vulnerable men in need of intervention.
” 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 Prisons and Probation Ombudsman; that does not assign responsibility.
PFD Monitor interpretation Restricted prison regimes
Wider context from the report “Concern 10: Staffing, supervision and regime limitations
The evidence before the court, including wider inspection material, raised concern that staffing pressures, weak supervision, poor staff-prisoner engagement, restricted regimes , and inadequate welfare observations may materially increase the risk of undetected drug use, delayed discovery of collapsed prisoners and failure to identify vulnerable men in need of intervention.
” 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 Prisons and Probation Ombudsman; that does not assign responsibility.
PFD Monitor interpretation Insufficiently robust identification and management of prisoners remaining behind their door because of vulnerability
Wider context from the report “Concern 5: Management of self-isolation, debt, fear and vulnerability
The evidence suggested that Mr Meikle had vulnerabilities connected to self-isolation, debt, fear of other prisoners, possible coercion or bullying, mental ill-health, and substance misuse. I am concerned that the systems for identifying and managing prisoners who remain behind their door because of debt, fear, vulnerability or drug-related pressures were not sufficiently robust, coordinated or escalated .
” 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 Prisons and Probation Ombudsman; that does not assign responsibility.
PFD Monitor interpretation Inadequate welfare observations
Wider context from the report “Concern 10: Staffing, supervision and regime limitations
The evidence before the court, including wider inspection material, raised concern that staffing pressures, weak supervision, poor staff-prisoner engagement, restricted regimes, and inadequate welfare observations may materially increase the risk of undetected drug use, delayed discovery of collapsed prisoners and failure to identify vulnerable men in need of intervention.
” 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 Prisons and Probation Ombudsman; that does not assign responsibility.
PFD Monitor interpretation Inconsistent identification, assessment, monitoring and response to prisoners under the influence of illicit substances
Wider context from the report “Concern 2: Failure consistently to identify, record and respond to prisoners under the influence
The evidence showed concerns about the consistency with which prisoners suspected or found to be under the influence of illicit substances were identified, clinically assessed, monitored, referred to substance misuse services, and managed under prison and healthcare processes . There was evidence that episodes of apparent intoxication were not always met with a consistent healthcare response or documented follow-up . The head of service had an understanding of the drug under the influence policy that was starkly different to the written document. There had been multiple updates of the drug policy which were difficult to identify as to when the policy was updated / revised. I am concerned that prisoners at acute risk of overdose or deterioration may therefore not receive timely intervention.
” 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 Prisons and Probation Ombudsman; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate prisoners with cumulative vulnerability indicators into safer custody procedures
Wider context from the report “Concern 6: Absence of ACCT despite identifiable indicators of vulnerability
The concern is not that ACCT documentation disclosed a missed risk factor, but that the available materials show Mr Meikle was not subject to ACCT proceedings, despite evidence shortly before death of self-isolation, debt-related vulnerability, known substance misuse and reduced engagement. This occurred in an establishment where HM Inspectorate of Prisons had already identified weaknesses in ACCT management and welfare checking during an unannounced inspection in 2023 and had issued an Urgent Notification which included reference to "frailties in ACCT case management". I later became aware of a second Urgent Notification issued in March 2026, shortly after completion of Mr Meikle's inquest that once again identified "frailties in ACCT case management". I am concerned that prisoners presenting with cumulative indicators of vulnerability may not be escalated into safer custody procedures when required , thereby increasing the risk that deteriorating welfare is not recognised or managed.
” 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 Prisons and Probation Ombudsman; that does not assign responsibility.
PFD Monitor interpretation Availability of illicit substances in custody
Wider context from the report “Concern 1: Availability of illicit substances in custody
The evidence indicated that illicit drugs ████████ were readily available within HMP Woodhill . Material before the court showed this was not an isolated issue but part of a wider and continuing prison safety problem at HMP Woodhill and likely other prisons . The availability of synthetic cannabinoids in custody creates a foreseeable risk of sudden collapse, respiratory compromise, cardiac arrest, psychosis, violence, self-harm and death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Prisons and Probation Ombudsman; that does not assign responsibility.
PFD Monitor interpretation Failure to reliably consolidate and share relevant prisoner risk information
Wider context from the report “Concern 3: Fragmented information-sharing and record keeping
The evidence demonstrated that relevant risk information was spread across multiple recording systems and was not always shared effectively between operational staff and clinical teams . This included information relevant to substance misuse, mental health, debt, bullying or coercion, self-isolation, intelligence about threats, recent presentation under the influence. Where critical safety information is held in separate systems and not reliably brought together , there is a foreseeable risk that warning signs will be missed and protective action delayed with obvious risk of harm or death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Prisons and Probation Ombudsman; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain unobstructed observation panels for effective visual welfare checks
Wider context from the report “Concern 4: Blocked observation panels and inadequate visual welfare checks
The evidence raised serious concern that blocked observation panels were not consistently challenged or cleared , and that visual welfare checks were therefore not always effective . The jury heard evidence that officers deliberately avoided opening blocked hatches to escape abuse from the prisoners then or later. In a prison environment where prisoners may be intoxicated, unconscious, self-harming, assaulted, or otherwise incapacitated behind a locked door, failure to maintain an unobstructed observation panel creates an obvious risk of late discovery and preventable death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Prisons and Probation Ombudsman; that does not assign responsibility.
PFD Monitor interpretation Delays in supplying material information relevant to death investigations and future-death prevention
Wider context from the report “Concern 12: Failure of state agencies to supply all information in a timely fashion.
In this Inquest I was presented with material information at the eleventh hour . Aside from being discourteous to the family and the Court such tardy provision has potential to frustrate a full investigation into the death and allow elements of care which may impact on future deaths to pass unnoticed .
” 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 Prisons and Probation Ombudsman; that does not assign responsibility.
PFD Monitor interpretation Failure to implement sufficient and sustained remedial action on identified prison safety concerns
Wider context from the report “Concern 11: Repeated systemic concerns at HMP Woodhill
Material before the court from oversight and inspection bodies demonstrated that concerns about drugs, safety, violence, self-isolation, observation panel compliance, ACCT weaknesses and welfare monitoring at HMP Woodhill had been identified over time. I am concerned that repeated identification of these issues has not resulted in sufficient or sustained remedial action , creating an ongoing risk of further deaths .
” 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 Prisons and Probation Ombudsman; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise IPP status as a material vulnerability requiring structured support and review
Wider context from the report “Concern 7: Particular vulnerability of prisoners serving IPP (Imprisonment for Public Protection) sentences
The evidence showed that prisoners serving IPP sentences may experience hopelessness, chronic frustration, deterioration in mental health and increased vulnerability to substance misuse and self-neglect . I am concerned that Mr Meikle's IPP status was not sufficiently recognised as a material risk factor requiring structured support, regular review and coordinated care .
” Open source report
2 May 2025 Sarah Frances BOYLE · Prevention of Future Deaths report Cheshire
View report summary
Concerns raised 8 Failure to respond reliably to expressions of self harm or suicidality View source ACCT observations failing to provide therapeutic support View source Insufficient mental health input for women not case loaded to the mental health team View source Delays in transferring women requiring mental health inpatient treatment View source Insufficient staffing capacity to complete ACCT checks and documentation View source Inconsistent completion of the ACCT process View source Insufficient mental health team capacity for women awaiting assessment or inpatient beds View source Insufficient mental health training and time for prison officers conducting meaningful ACCT conversations View source See 5 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
Sarah Frances BOYLE · 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
Sarah Boyle was detained at HMP Styal and was monitored under the ACCT process after expressing thoughts of self-harm or suicide and making several ligature attempts. On 14 July 2024, she was found with a ligature around her neck, suffered irreversible brain damage, and died in hospital on 20 July 2024. The report raises concerns that the ACCT process at HMP Styal was not working effectively, citing high levels of self-harm, complex mental-health needs, understaffing, missed checks, and inconsistent completion of the process.
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 Prisons and Probation Ombudsman; that does not assign responsibility.
PFD Monitor interpretation Failure to respond reliably to expressions of self harm or suicidality
Wider context from the report “I am concerned that the ACCT process or system currently in place designed to keep women safe at HMP Styal is not working effectively, and that there is a risk of future deaths if the process is not reconsidered or amended to better suit the needs of this prison. The ACCT process allows for observations of a woman who is at risk of self harm or suicide to keep her safe, but these are not a therapeutic observation and are essentially a check to ensure that the woman is alive and not actively self harming. Mental health input, if a woman is not case loaded to the mental health team, can be minimal, limited to attendance at a case review at best, and this does not allow for an opportunity to improve the woman’s mental health, to reduce the risk of future suicide attempts. Care plans allowing for meaningful activity assist but their effectiveness is limited alongside the prison regime. I acknowledge that prison is not intended to be a therapeutic environment but given the number of women with mental health needs, I am concerned that the current environment or processes will give rise to a risk of future deaths.
My concerns are based on the following points which I heard in evidence:
• HMP Styal is a women’s prison with a high number of self inflicted deaths, compared to the rest of the female estate. I am told by the prison ombudsman that they have the highest number of deaths between January 2022 and January 2025, accounting on my calculation for almost half of the total deaths in the female estate across England. I am aware that there has been one self inflicted death this year to date, and we are only 4 months in;
• I heard evidence from the Head of Safer Prisons and Equality at HMP Styal and the Service Manager for Greater Manchester Mental Health NHS FT, who provide the mental health care in the prison, that the mental health needs of the women detained at Styal are high and can be complex. The latter explained that they receive women from court who have been sent to prison following a criminal act but are essentially awaiting assessment to see whether they should be detained in prison, or in a mental health hospital. The mental health team is then expected to care for the woman for the prolonged period of assessment and awaiting a bed if deemed necessary, something they are not set up to do. It was the view of this witness that Styal was receiving a number of prisoners who are complex and risky and require treatment in a mental health hospital. The process for transfer then takes time and is an additional pressure on the team. The powers of a mental health team in prison are far more restricted, for example, they cannot force medication if needed, and it is reliant on the engagement of prisoners which they frequently do not get. The mental health Trust confirmed that in 2025 to date (29.4.25), 11 prisoners have been referred for a Mental Health Act assessment and of these 11, 8 were accepted for transfer and treatment in a mental health inpatient setting;
• It was the evidence of the Head of Safer Prisons and Equality that they also receive women who are there for a ‘warrant of concern’. A ‘warrant of concern’ is where a woman attends court and is not sentenced at that point but remanded into prison custody due to the Judge having concerns that they are not safe to be released into the community and where it is perceived that they will be safer in custody. This is usually where there are concerns around the woman’s mental health and/or risk to self. This adds pressure on an already stretched resource level in prisons as more resources are generally required to manage such complex individuals; Prison data suggests that HMP Styal have received 7 women on ‘warrants of concern’ since November 2024 to date (April 2025);
• I heard from one witness that a ‘good day’ on one side of the wing would just be one incident of self harm, but there would be frequently multiple incidents;
• The number of number of self harm incidents and ACCT documents open appears to have hardened the prison team to expressions of self harm etc. I heard comments throughout the inquest such as “If I opened an ACCT on every woman who said she was suicidal we’d have loads open”, and “2 incidents of self harm in a morning for one prisoner might seem like a lot but it’s not in the context of Styal”. This may lead to key cases being missed ;
• The number of ACCTs open within the prison can be high given the mental health need. I have heard evidence from a number of witnesses as to the pressures that the ACCT process places on staff, primarily due to the high number compared to staffing numbers. The severity of this varied in evidence depending seemingly on whether the member of staff was still with the prison service or had left. The clear consensus however was that the carrying out of ACCT checks, meaningful conversations and documentation of this was difficult whilst also trying to manage the day to day regime. It was accepted by the Head of Safer Prisons and Equality at HMP Styal that the officer on duty on the day of Sarah’s death would have been responsible for 48 checks an hour, and that was not unusual. Evidence from one witness, who has since left the prison, was that as a result of the number of checks required, and the limited resource to do them, checks were frequently missed;
• Meaningful conversations, designed to find out how the person is feeling and check in with them, are being carried out by prison officers with very limited mental health training, with very limited time resource to do this. Mental health training is not mandatory for the officers and can be overlooked due to more pressing, mandatory training.
The jury findings record “Understaffing and a high number of ACCT documents at HMP Styal led to inconsistencies with how staff completed each part of the ACCT process”.
In addition to the evidence heard from the witnesses, I am mindful of the report of HM Chief Inspector of Prisons (Time to care: what helps women cope in prison February 2025) which notes that the rate of self harm among women in prison is now 8.5 times higher than in men’s jails, and highlights a number of issues which continue to this, which have been reflected in this 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 Prisons and Probation Ombudsman; that does not assign responsibility.
PFD Monitor interpretation ACCT observations failing to provide therapeutic support
Wider context from the report “I am concerned that the ACCT process or system currently in place designed to keep women safe at HMP Styal is not working effectively, and that there is a risk of future deaths if the process is not reconsidered or amended to better suit the needs of this prison. The ACCT process allows for observations of a woman who is at risk of self harm or suicide to keep her safe, but these are not a therapeutic observation and are essentially a check to ensure that the woman is alive and not actively self harming . Mental health input, if a woman is not case loaded to the mental health team, can be minimal, limited to attendance at a case review at best, and this does not allow for an opportunity to improve the woman’s mental health, to reduce the risk of future suicide attempts. Care plans allowing for meaningful activity assist but their effectiveness is limited alongside the prison regime. I acknowledge that prison is not intended to be a therapeutic environment but given the number of women with mental health needs, I am concerned that the current environment or processes will give rise to a risk of future deaths.
My concerns are based on the following points which I heard in evidence:
• HMP Styal is a women’s prison with a high number of self inflicted deaths, compared to the rest of the female estate. I am told by the prison ombudsman that they have the highest number of deaths between January 2022 and January 2025, accounting on my calculation for almost half of the total deaths in the female estate across England. I am aware that there has been one self inflicted death this year to date, and we are only 4 months in;
• I heard evidence from the Head of Safer Prisons and Equality at HMP Styal and the Service Manager for Greater Manchester Mental Health NHS FT, who provide the mental health care in the prison, that the mental health needs of the women detained at Styal are high and can be complex. The latter explained that they receive women from court who have been sent to prison following a criminal act but are essentially awaiting assessment to see whether they should be detained in prison, or in a mental health hospital. The mental health team is then expected to care for the woman for the prolonged period of assessment and awaiting a bed if deemed necessary, something they are not set up to do. It was the view of this witness that Styal was receiving a number of prisoners who are complex and risky and require treatment in a mental health hospital. The process for transfer then takes time and is an additional pressure on the team. The powers of a mental health team in prison are far more restricted, for example, they cannot force medication if needed, and it is reliant on the engagement of prisoners which they frequently do not get. The mental health Trust confirmed that in 2025 to date (29.4.25), 11 prisoners have been referred for a Mental Health Act assessment and of these 11, 8 were accepted for transfer and treatment in a mental health inpatient setting;
• It was the evidence of the Head of Safer Prisons and Equality that they also receive women who are there for a ‘warrant of concern’. A ‘warrant of concern’ is where a woman attends court and is not sentenced at that point but remanded into prison custody due to the Judge having concerns that they are not safe to be released into the community and where it is perceived that they will be safer in custody. This is usually where there are concerns around the woman’s mental health and/or risk to self. This adds pressure on an already stretched resource level in prisons as more resources are generally required to manage such complex individuals; Prison data suggests that HMP Styal have received 7 women on ‘warrants of concern’ since November 2024 to date (April 2025);
• I heard from one witness that a ‘good day’ on one side of the wing would just be one incident of self harm, but there would be frequently multiple incidents;
• The number of number of self harm incidents and ACCT documents open appears to have hardened the prison team to expressions of self harm etc. I heard comments throughout the inquest such as “If I opened an ACCT on every woman who said she was suicidal we’d have loads open”, and “2 incidents of self harm in a morning for one prisoner might seem like a lot but it’s not in the context of Styal”. This may lead to key cases being missed;
• The number of ACCTs open within the prison can be high given the mental health need. I have heard evidence from a number of witnesses as to the pressures that the ACCT process places on staff, primarily due to the high number compared to staffing numbers. The severity of this varied in evidence depending seemingly on whether the member of staff was still with the prison service or had left. The clear consensus however was that the carrying out of ACCT checks, meaningful conversations and documentation of this was difficult whilst also trying to manage the day to day regime. It was accepted by the Head of Safer Prisons and Equality at HMP Styal that the officer on duty on the day of Sarah’s death would have been responsible for 48 checks an hour, and that was not unusual. Evidence from one witness, who has since left the prison, was that as a result of the number of checks required, and the limited resource to do them, checks were frequently missed;
• Meaningful conversations, designed to find out how the person is feeling and check in with them, are being carried out by prison officers with very limited mental health training, with very limited time resource to do this. Mental health training is not mandatory for the officers and can be overlooked due to more pressing, mandatory training.
The jury findings record “Understaffing and a high number of ACCT documents at HMP Styal led to inconsistencies with how staff completed each part of the ACCT process”.
In addition to the evidence heard from the witnesses, I am mindful of the report of HM Chief Inspector of Prisons (Time to care: what helps women cope in prison February 2025) which notes that the rate of self harm among women in prison is now 8.5 times higher than in men’s jails, and highlights a number of issues which continue to this, which have been reflected in this 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 Prisons and Probation Ombudsman; that does not assign responsibility.
PFD Monitor interpretation Insufficient mental health input for women not case loaded to the mental health team
Wider context from the report “I am concerned that the ACCT process or system currently in place designed to keep women safe at HMP Styal is not working effectively, and that there is a risk of future deaths if the process is not reconsidered or amended to better suit the needs of this prison. The ACCT process allows for observations of a woman who is at risk of self harm or suicide to keep her safe, but these are not a therapeutic observation and are essentially a check to ensure that the woman is alive and not actively self harming. Mental health input, if a woman is not case loaded to the mental health team, can be minimal, limited to attendance at a case review at best , and this does not allow for an opportunity to improve the woman’s mental health, to reduce the risk of future suicide attempts. Care plans allowing for meaningful activity assist but their effectiveness is limited alongside the prison regime. I acknowledge that prison is not intended to be a therapeutic environment but given the number of women with mental health needs, I am concerned that the current environment or processes will give rise to a risk of future deaths.
My concerns are based on the following points which I heard in evidence:
• HMP Styal is a women’s prison with a high number of self inflicted deaths, compared to the rest of the female estate. I am told by the prison ombudsman that they have the highest number of deaths between January 2022 and January 2025, accounting on my calculation for almost half of the total deaths in the female estate across England. I am aware that there has been one self inflicted death this year to date, and we are only 4 months in;
• I heard evidence from the Head of Safer Prisons and Equality at HMP Styal and the Service Manager for Greater Manchester Mental Health NHS FT, who provide the mental health care in the prison, that the mental health needs of the women detained at Styal are high and can be complex. The latter explained that they receive women from court who have been sent to prison following a criminal act but are essentially awaiting assessment to see whether they should be detained in prison, or in a mental health hospital. The mental health team is then expected to care for the woman for the prolonged period of assessment and awaiting a bed if deemed necessary, something they are not set up to do. It was the view of this witness that Styal was receiving a number of prisoners who are complex and risky and require treatment in a mental health hospital. The process for transfer then takes time and is an additional pressure on the team. The powers of a mental health team in prison are far more restricted, for example, they cannot force medication if needed, and it is reliant on the engagement of prisoners which they frequently do not get. The mental health Trust confirmed that in 2025 to date (29.4.25), 11 prisoners have been referred for a Mental Health Act assessment and of these 11, 8 were accepted for transfer and treatment in a mental health inpatient setting;
• It was the evidence of the Head of Safer Prisons and Equality that they also receive women who are there for a ‘warrant of concern’. A ‘warrant of concern’ is where a woman attends court and is not sentenced at that point but remanded into prison custody due to the Judge having concerns that they are not safe to be released into the community and where it is perceived that they will be safer in custody. This is usually where there are concerns around the woman’s mental health and/or risk to self. This adds pressure on an already stretched resource level in prisons as more resources are generally required to manage such complex individuals; Prison data suggests that HMP Styal have received 7 women on ‘warrants of concern’ since November 2024 to date (April 2025);
• I heard from one witness that a ‘good day’ on one side of the wing would just be one incident of self harm, but there would be frequently multiple incidents;
• The number of number of self harm incidents and ACCT documents open appears to have hardened the prison team to expressions of self harm etc. I heard comments throughout the inquest such as “If I opened an ACCT on every woman who said she was suicidal we’d have loads open”, and “2 incidents of self harm in a morning for one prisoner might seem like a lot but it’s not in the context of Styal”. This may lead to key cases being missed;
• The number of ACCTs open within the prison can be high given the mental health need. I have heard evidence from a number of witnesses as to the pressures that the ACCT process places on staff, primarily due to the high number compared to staffing numbers. The severity of this varied in evidence depending seemingly on whether the member of staff was still with the prison service or had left. The clear consensus however was that the carrying out of ACCT checks, meaningful conversations and documentation of this was difficult whilst also trying to manage the day to day regime. It was accepted by the Head of Safer Prisons and Equality at HMP Styal that the officer on duty on the day of Sarah’s death would have been responsible for 48 checks an hour, and that was not unusual. Evidence from one witness, who has since left the prison, was that as a result of the number of checks required, and the limited resource to do them, checks were frequently missed;
• Meaningful conversations, designed to find out how the person is feeling and check in with them, are being carried out by prison officers with very limited mental health training, with very limited time resource to do this. Mental health training is not mandatory for the officers and can be overlooked due to more pressing, mandatory training.
The jury findings record “Understaffing and a high number of ACCT documents at HMP Styal led to inconsistencies with how staff completed each part of the ACCT process”.
In addition to the evidence heard from the witnesses, I am mindful of the report of HM Chief Inspector of Prisons (Time to care: what helps women cope in prison February 2025) which notes that the rate of self harm among women in prison is now 8.5 times higher than in men’s jails, and highlights a number of issues which continue to this, which have been reflected in this 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 Prisons and Probation Ombudsman; that does not assign responsibility.
PFD Monitor interpretation Delays in transferring women requiring mental health inpatient treatment
Wider context from the report “I am concerned that the ACCT process or system currently in place designed to keep women safe at HMP Styal is not working effectively, and that there is a risk of future deaths if the process is not reconsidered or amended to better suit the needs of this prison. The ACCT process allows for observations of a woman who is at risk of self harm or suicide to keep her safe, but these are not a therapeutic observation and are essentially a check to ensure that the woman is alive and not actively self harming. Mental health input, if a woman is not case loaded to the mental health team, can be minimal, limited to attendance at a case review at best, and this does not allow for an opportunity to improve the woman’s mental health, to reduce the risk of future suicide attempts. Care plans allowing for meaningful activity assist but their effectiveness is limited alongside the prison regime. I acknowledge that prison is not intended to be a therapeutic environment but given the number of women with mental health needs, I am concerned that the current environment or processes will give rise to a risk of future deaths.
My concerns are based on the following points which I heard in evidence:
• HMP Styal is a women’s prison with a high number of self inflicted deaths, compared to the rest of the female estate. I am told by the prison ombudsman that they have the highest number of deaths between January 2022 and January 2025, accounting on my calculation for almost half of the total deaths in the female estate across England. I am aware that there has been one self inflicted death this year to date, and we are only 4 months in;
• I heard evidence from the Head of Safer Prisons and Equality at HMP Styal and the Service Manager for Greater Manchester Mental Health NHS FT, who provide the mental health care in the prison, that the mental health needs of the women detained at Styal are high and can be complex. The latter explained that they receive women from court who have been sent to prison following a criminal act but are essentially awaiting assessment to see whether they should be detained in prison, or in a mental health hospital. The mental health team is then expected to care for the woman for the prolonged period of assessment and awaiting a bed if deemed necessary, something they are not set up to do. It was the view of this witness that Styal was receiving a number of prisoners who are complex and risky and require treatment in a mental health hospital. The process for transfer then takes time and is an additional pressure on the team . The powers of a mental health team in prison are far more restricted, for example, they cannot force medication if needed, and it is reliant on the engagement of prisoners which they frequently do not get. The mental health Trust confirmed that in 2025 to date (29.4.25), 11 prisoners have been referred for a Mental Health Act assessment and of these 11, 8 were accepted for transfer and treatment in a mental health inpatient setting;
• It was the evidence of the Head of Safer Prisons and Equality that they also receive women who are there for a ‘warrant of concern’. A ‘warrant of concern’ is where a woman attends court and is not sentenced at that point but remanded into prison custody due to the Judge having concerns that they are not safe to be released into the community and where it is perceived that they will be safer in custody. This is usually where there are concerns around the woman’s mental health and/or risk to self. This adds pressure on an already stretched resource level in prisons as more resources are generally required to manage such complex individuals; Prison data suggests that HMP Styal have received 7 women on ‘warrants of concern’ since November 2024 to date (April 2025);
• I heard from one witness that a ‘good day’ on one side of the wing would just be one incident of self harm, but there would be frequently multiple incidents;
• The number of number of self harm incidents and ACCT documents open appears to have hardened the prison team to expressions of self harm etc. I heard comments throughout the inquest such as “If I opened an ACCT on every woman who said she was suicidal we’d have loads open”, and “2 incidents of self harm in a morning for one prisoner might seem like a lot but it’s not in the context of Styal”. This may lead to key cases being missed;
• The number of ACCTs open within the prison can be high given the mental health need. I have heard evidence from a number of witnesses as to the pressures that the ACCT process places on staff, primarily due to the high number compared to staffing numbers. The severity of this varied in evidence depending seemingly on whether the member of staff was still with the prison service or had left. The clear consensus however was that the carrying out of ACCT checks, meaningful conversations and documentation of this was difficult whilst also trying to manage the day to day regime. It was accepted by the Head of Safer Prisons and Equality at HMP Styal that the officer on duty on the day of Sarah’s death would have been responsible for 48 checks an hour, and that was not unusual. Evidence from one witness, who has since left the prison, was that as a result of the number of checks required, and the limited resource to do them, checks were frequently missed;
• Meaningful conversations, designed to find out how the person is feeling and check in with them, are being carried out by prison officers with very limited mental health training, with very limited time resource to do this. Mental health training is not mandatory for the officers and can be overlooked due to more pressing, mandatory training.
The jury findings record “Understaffing and a high number of ACCT documents at HMP Styal led to inconsistencies with how staff completed each part of the ACCT process”.
In addition to the evidence heard from the witnesses, I am mindful of the report of HM Chief Inspector of Prisons (Time to care: what helps women cope in prison February 2025) which notes that the rate of self harm among women in prison is now 8.5 times higher than in men’s jails, and highlights a number of issues which continue to this, which have been reflected in this 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 Prisons and Probation Ombudsman; that does not assign responsibility.
PFD Monitor interpretation Insufficient staffing capacity to complete ACCT checks and documentation
Wider context from the report “I am concerned that the ACCT process or system currently in place designed to keep women safe at HMP Styal is not working effectively, and that there is a risk of future deaths if the process is not reconsidered or amended to better suit the needs of this prison. The ACCT process allows for observations of a woman who is at risk of self harm or suicide to keep her safe, but these are not a therapeutic observation and are essentially a check to ensure that the woman is alive and not actively self harming. Mental health input, if a woman is not case loaded to the mental health team, can be minimal, limited to attendance at a case review at best, and this does not allow for an opportunity to improve the woman’s mental health, to reduce the risk of future suicide attempts. Care plans allowing for meaningful activity assist but their effectiveness is limited alongside the prison regime. I acknowledge that prison is not intended to be a therapeutic environment but given the number of women with mental health needs, I am concerned that the current environment or processes will give rise to a risk of future deaths.
My concerns are based on the following points which I heard in evidence:
• HMP Styal is a women’s prison with a high number of self inflicted deaths, compared to the rest of the female estate. I am told by the prison ombudsman that they have the highest number of deaths between January 2022 and January 2025, accounting on my calculation for almost half of the total deaths in the female estate across England. I am aware that there has been one self inflicted death this year to date, and we are only 4 months in;
• I heard evidence from the Head of Safer Prisons and Equality at HMP Styal and the Service Manager for Greater Manchester Mental Health NHS FT, who provide the mental health care in the prison, that the mental health needs of the women detained at Styal are high and can be complex. The latter explained that they receive women from court who have been sent to prison following a criminal act but are essentially awaiting assessment to see whether they should be detained in prison, or in a mental health hospital. The mental health team is then expected to care for the woman for the prolonged period of assessment and awaiting a bed if deemed necessary, something they are not set up to do. It was the view of this witness that Styal was receiving a number of prisoners who are complex and risky and require treatment in a mental health hospital. The process for transfer then takes time and is an additional pressure on the team. The powers of a mental health team in prison are far more restricted, for example, they cannot force medication if needed, and it is reliant on the engagement of prisoners which they frequently do not get. The mental health Trust confirmed that in 2025 to date (29.4.25), 11 prisoners have been referred for a Mental Health Act assessment and of these 11, 8 were accepted for transfer and treatment in a mental health inpatient setting;
• It was the evidence of the Head of Safer Prisons and Equality that they also receive women who are there for a ‘warrant of concern’. A ‘warrant of concern’ is where a woman attends court and is not sentenced at that point but remanded into prison custody due to the Judge having concerns that they are not safe to be released into the community and where it is perceived that they will be safer in custody. This is usually where there are concerns around the woman’s mental health and/or risk to self. This adds pressure on an already stretched resource level in prisons as more resources are generally required to manage such complex individuals; Prison data suggests that HMP Styal have received 7 women on ‘warrants of concern’ since November 2024 to date (April 2025);
• I heard from one witness that a ‘good day’ on one side of the wing would just be one incident of self harm, but there would be frequently multiple incidents;
• The number of number of self harm incidents and ACCT documents open appears to have hardened the prison team to expressions of self harm etc. I heard comments throughout the inquest such as “If I opened an ACCT on every woman who said she was suicidal we’d have loads open”, and “2 incidents of self harm in a morning for one prisoner might seem like a lot but it’s not in the context of Styal”. This may lead to key cases being missed;
• The number of ACCTs open within the prison can be high given the mental health need. I have heard evidence from a number of witnesses as to the pressures that the ACCT process places on staff, primarily due to the high number compared to staffing numbers. The severity of this varied in evidence depending seemingly on whether the member of staff was still with the prison service or had left. The clear consensus however was that the carrying out of ACCT checks, meaningful conversations and documentation of this was difficult whilst also trying to manage the day to day regime . It was accepted by the Head of Safer Prisons and Equality at HMP Styal that the officer on duty on the day of Sarah’s death would have been responsible for 48 checks an hour, and that was not unusual. Evidence from one witness, who has since left the prison, was that as a result of the number of checks required, and the limited resource to do them, checks were frequently missed ;
• Meaningful conversations, designed to find out how the person is feeling and check in with them, are being carried out by prison officers with very limited mental health training, with very limited time resource to do this. Mental health training is not mandatory for the officers and can be overlooked due to more pressing, mandatory training.
The jury findings record “Understaffing and a high number of ACCT documents at HMP Styal led to inconsistencies with how staff completed each part of the ACCT process”.
In addition to the evidence heard from the witnesses, I am mindful of the report of HM Chief Inspector of Prisons (Time to care: what helps women cope in prison February 2025) which notes that the rate of self harm among women in prison is now 8.5 times higher than in men’s jails, and highlights a number of issues which continue to this, which have been reflected in this 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 Prisons and Probation Ombudsman; that does not assign responsibility.
PFD Monitor interpretation Inconsistent completion of the ACCT process
Wider context from the report “I am concerned that the ACCT process or system currently in place designed to keep women safe at HMP Styal is not working effectively, and that there is a risk of future deaths if the process is not reconsidered or amended to better suit the needs of this prison. The ACCT process allows for observations of a woman who is at risk of self harm or suicide to keep her safe, but these are not a therapeutic observation and are essentially a check to ensure that the woman is alive and not actively self harming. Mental health input, if a woman is not case loaded to the mental health team, can be minimal, limited to attendance at a case review at best, and this does not allow for an opportunity to improve the woman’s mental health, to reduce the risk of future suicide attempts. Care plans allowing for meaningful activity assist but their effectiveness is limited alongside the prison regime. I acknowledge that prison is not intended to be a therapeutic environment but given the number of women with mental health needs, I am concerned that the current environment or processes will give rise to a risk of future deaths.
My concerns are based on the following points which I heard in evidence:
• HMP Styal is a women’s prison with a high number of self inflicted deaths, compared to the rest of the female estate. I am told by the prison ombudsman that they have the highest number of deaths between January 2022 and January 2025, accounting on my calculation for almost half of the total deaths in the female estate across England. I am aware that there has been one self inflicted death this year to date, and we are only 4 months in;
• I heard evidence from the Head of Safer Prisons and Equality at HMP Styal and the Service Manager for Greater Manchester Mental Health NHS FT, who provide the mental health care in the prison, that the mental health needs of the women detained at Styal are high and can be complex. The latter explained that they receive women from court who have been sent to prison following a criminal act but are essentially awaiting assessment to see whether they should be detained in prison, or in a mental health hospital. The mental health team is then expected to care for the woman for the prolonged period of assessment and awaiting a bed if deemed necessary, something they are not set up to do. It was the view of this witness that Styal was receiving a number of prisoners who are complex and risky and require treatment in a mental health hospital. The process for transfer then takes time and is an additional pressure on the team. The powers of a mental health team in prison are far more restricted, for example, they cannot force medication if needed, and it is reliant on the engagement of prisoners which they frequently do not get. The mental health Trust confirmed that in 2025 to date (29.4.25), 11 prisoners have been referred for a Mental Health Act assessment and of these 11, 8 were accepted for transfer and treatment in a mental health inpatient setting;
• It was the evidence of the Head of Safer Prisons and Equality that they also receive women who are there for a ‘warrant of concern’. A ‘warrant of concern’ is where a woman attends court and is not sentenced at that point but remanded into prison custody due to the Judge having concerns that they are not safe to be released into the community and where it is perceived that they will be safer in custody. This is usually where there are concerns around the woman’s mental health and/or risk to self. This adds pressure on an already stretched resource level in prisons as more resources are generally required to manage such complex individuals; Prison data suggests that HMP Styal have received 7 women on ‘warrants of concern’ since November 2024 to date (April 2025);
• I heard from one witness that a ‘good day’ on one side of the wing would just be one incident of self harm, but there would be frequently multiple incidents;
• The number of number of self harm incidents and ACCT documents open appears to have hardened the prison team to expressions of self harm etc. I heard comments throughout the inquest such as “If I opened an ACCT on every woman who said she was suicidal we’d have loads open”, and “2 incidents of self harm in a morning for one prisoner might seem like a lot but it’s not in the context of Styal”. This may lead to key cases being missed;
• The number of ACCTs open within the prison can be high given the mental health need. I have heard evidence from a number of witnesses as to the pressures that the ACCT process places on staff, primarily due to the high number compared to staffing numbers. The severity of this varied in evidence depending seemingly on whether the member of staff was still with the prison service or had left. The clear consensus however was that the carrying out of ACCT checks, meaningful conversations and documentation of this was difficult whilst also trying to manage the day to day regime. It was accepted by the Head of Safer Prisons and Equality at HMP Styal that the officer on duty on the day of Sarah’s death would have been responsible for 48 checks an hour, and that was not unusual. Evidence from one witness, who has since left the prison, was that as a result of the number of checks required, and the limited resource to do them, checks were frequently missed;
• Meaningful conversations, designed to find out how the person is feeling and check in with them, are being carried out by prison officers with very limited mental health training, with very limited time resource to do this. Mental health training is not mandatory for the officers and can be overlooked due to more pressing, mandatory training.
The jury findings record “Understaffing and a high number of ACCT documents at HMP Styal led to inconsistencies with how staff completed each part of the ACCT process ”.
In addition to the evidence heard from the witnesses, I am mindful of the report of HM Chief Inspector of Prisons (Time to care: what helps women cope in prison February 2025) which notes that the rate of self harm among women in prison is now 8.5 times higher than in men’s jails, and highlights a number of issues which continue to this, which have been reflected in this 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 Prisons and Probation Ombudsman; that does not assign responsibility.
PFD Monitor interpretation Insufficient mental health team capacity for women awaiting assessment or inpatient beds
Wider context from the report “I am concerned that the ACCT process or system currently in place designed to keep women safe at HMP Styal is not working effectively, and that there is a risk of future deaths if the process is not reconsidered or amended to better suit the needs of this prison. The ACCT process allows for observations of a woman who is at risk of self harm or suicide to keep her safe, but these are not a therapeutic observation and are essentially a check to ensure that the woman is alive and not actively self harming. Mental health input, if a woman is not case loaded to the mental health team, can be minimal, limited to attendance at a case review at best, and this does not allow for an opportunity to improve the woman’s mental health, to reduce the risk of future suicide attempts. Care plans allowing for meaningful activity assist but their effectiveness is limited alongside the prison regime. I acknowledge that prison is not intended to be a therapeutic environment but given the number of women with mental health needs, I am concerned that the current environment or processes will give rise to a risk of future deaths.
My concerns are based on the following points which I heard in evidence:
• HMP Styal is a women’s prison with a high number of self inflicted deaths, compared to the rest of the female estate. I am told by the prison ombudsman that they have the highest number of deaths between January 2022 and January 2025, accounting on my calculation for almost half of the total deaths in the female estate across England. I am aware that there has been one self inflicted death this year to date, and we are only 4 months in;
• I heard evidence from the Head of Safer Prisons and Equality at HMP Styal and the Service Manager for Greater Manchester Mental Health NHS FT, who provide the mental health care in the prison, that the mental health needs of the women detained at Styal are high and can be complex. The latter explained that they receive women from court who have been sent to prison following a criminal act but are essentially awaiting assessment to see whether they should be detained in prison, or in a mental health hospital. The mental health team is then expected to care for the woman for the prolonged period of assessment and awaiting a bed if deemed necessary, something they are not set up to do . It was the view of this witness that Styal was receiving a number of prisoners who are complex and risky and require treatment in a mental health hospital. The process for transfer then takes time and is an additional pressure on the team. The powers of a mental health team in prison are far more restricted, for example, they cannot force medication if needed, and it is reliant on the engagement of prisoners which they frequently do not get. The mental health Trust confirmed that in 2025 to date (29.4.25), 11 prisoners have been referred for a Mental Health Act assessment and of these 11, 8 were accepted for transfer and treatment in a mental health inpatient setting;
• It was the evidence of the Head of Safer Prisons and Equality that they also receive women who are there for a ‘warrant of concern’. A ‘warrant of concern’ is where a woman attends court and is not sentenced at that point but remanded into prison custody due to the Judge having concerns that they are not safe to be released into the community and where it is perceived that they will be safer in custody. This is usually where there are concerns around the woman’s mental health and/or risk to self. This adds pressure on an already stretched resource level in prisons as more resources are generally required to manage such complex individuals; Prison data suggests that HMP Styal have received 7 women on ‘warrants of concern’ since November 2024 to date (April 2025);
• I heard from one witness that a ‘good day’ on one side of the wing would just be one incident of self harm, but there would be frequently multiple incidents;
• The number of number of self harm incidents and ACCT documents open appears to have hardened the prison team to expressions of self harm etc. I heard comments throughout the inquest such as “If I opened an ACCT on every woman who said she was suicidal we’d have loads open”, and “2 incidents of self harm in a morning for one prisoner might seem like a lot but it’s not in the context of Styal”. This may lead to key cases being missed;
• The number of ACCTs open within the prison can be high given the mental health need. I have heard evidence from a number of witnesses as to the pressures that the ACCT process places on staff, primarily due to the high number compared to staffing numbers. The severity of this varied in evidence depending seemingly on whether the member of staff was still with the prison service or had left. The clear consensus however was that the carrying out of ACCT checks, meaningful conversations and documentation of this was difficult whilst also trying to manage the day to day regime. It was accepted by the Head of Safer Prisons and Equality at HMP Styal that the officer on duty on the day of Sarah’s death would have been responsible for 48 checks an hour, and that was not unusual. Evidence from one witness, who has since left the prison, was that as a result of the number of checks required, and the limited resource to do them, checks were frequently missed;
• Meaningful conversations, designed to find out how the person is feeling and check in with them, are being carried out by prison officers with very limited mental health training, with very limited time resource to do this. Mental health training is not mandatory for the officers and can be overlooked due to more pressing, mandatory training.
The jury findings record “Understaffing and a high number of ACCT documents at HMP Styal led to inconsistencies with how staff completed each part of the ACCT process”.
In addition to the evidence heard from the witnesses, I am mindful of the report of HM Chief Inspector of Prisons (Time to care: what helps women cope in prison February 2025) which notes that the rate of self harm among women in prison is now 8.5 times higher than in men’s jails, and highlights a number of issues which continue to this, which have been reflected in this 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 Prisons and Probation Ombudsman; that does not assign responsibility.
PFD Monitor interpretation Insufficient mental health training and time for prison officers conducting meaningful ACCT conversations
Wider context from the report “I am concerned that the ACCT process or system currently in place designed to keep women safe at HMP Styal is not working effectively, and that there is a risk of future deaths if the process is not reconsidered or amended to better suit the needs of this prison. The ACCT process allows for observations of a woman who is at risk of self harm or suicide to keep her safe, but these are not a therapeutic observation and are essentially a check to ensure that the woman is alive and not actively self harming. Mental health input, if a woman is not case loaded to the mental health team, can be minimal, limited to attendance at a case review at best, and this does not allow for an opportunity to improve the woman’s mental health, to reduce the risk of future suicide attempts. Care plans allowing for meaningful activity assist but their effectiveness is limited alongside the prison regime. I acknowledge that prison is not intended to be a therapeutic environment but given the number of women with mental health needs, I am concerned that the current environment or processes will give rise to a risk of future deaths.
My concerns are based on the following points which I heard in evidence:
• HMP Styal is a women’s prison with a high number of self inflicted deaths, compared to the rest of the female estate. I am told by the prison ombudsman that they have the highest number of deaths between January 2022 and January 2025, accounting on my calculation for almost half of the total deaths in the female estate across England. I am aware that there has been one self inflicted death this year to date, and we are only 4 months in;
• I heard evidence from the Head of Safer Prisons and Equality at HMP Styal and the Service Manager for Greater Manchester Mental Health NHS FT, who provide the mental health care in the prison, that the mental health needs of the women detained at Styal are high and can be complex. The latter explained that they receive women from court who have been sent to prison following a criminal act but are essentially awaiting assessment to see whether they should be detained in prison, or in a mental health hospital. The mental health team is then expected to care for the woman for the prolonged period of assessment and awaiting a bed if deemed necessary, something they are not set up to do. It was the view of this witness that Styal was receiving a number of prisoners who are complex and risky and require treatment in a mental health hospital. The process for transfer then takes time and is an additional pressure on the team. The powers of a mental health team in prison are far more restricted, for example, they cannot force medication if needed, and it is reliant on the engagement of prisoners which they frequently do not get. The mental health Trust confirmed that in 2025 to date (29.4.25), 11 prisoners have been referred for a Mental Health Act assessment and of these 11, 8 were accepted for transfer and treatment in a mental health inpatient setting;
• It was the evidence of the Head of Safer Prisons and Equality that they also receive women who are there for a ‘warrant of concern’. A ‘warrant of concern’ is where a woman attends court and is not sentenced at that point but remanded into prison custody due to the Judge having concerns that they are not safe to be released into the community and where it is perceived that they will be safer in custody. This is usually where there are concerns around the woman’s mental health and/or risk to self. This adds pressure on an already stretched resource level in prisons as more resources are generally required to manage such complex individuals; Prison data suggests that HMP Styal have received 7 women on ‘warrants of concern’ since November 2024 to date (April 2025);
• I heard from one witness that a ‘good day’ on one side of the wing would just be one incident of self harm, but there would be frequently multiple incidents;
• The number of number of self harm incidents and ACCT documents open appears to have hardened the prison team to expressions of self harm etc. I heard comments throughout the inquest such as “If I opened an ACCT on every woman who said she was suicidal we’d have loads open”, and “2 incidents of self harm in a morning for one prisoner might seem like a lot but it’s not in the context of Styal”. This may lead to key cases being missed;
• The number of ACCTs open within the prison can be high given the mental health need. I have heard evidence from a number of witnesses as to the pressures that the ACCT process places on staff, primarily due to the high number compared to staffing numbers. The severity of this varied in evidence depending seemingly on whether the member of staff was still with the prison service or had left. The clear consensus however was that the carrying out of ACCT checks, meaningful conversations and documentation of this was difficult whilst also trying to manage the day to day regime. It was accepted by the Head of Safer Prisons and Equality at HMP Styal that the officer on duty on the day of Sarah’s death would have been responsible for 48 checks an hour, and that was not unusual. Evidence from one witness, who has since left the prison, was that as a result of the number of checks required, and the limited resource to do them, checks were frequently missed;
• Meaningful conversations, designed to find out how the person is feeling and check in with them, are being carried out by prison officers with very limited mental health training, with very limited time resource to do this. Mental health training is not mandatory for the officers and can be overlooked due to more pressing, mandatory training.
The jury findings record “Understaffing and a high number of ACCT documents at HMP Styal led to inconsistencies with how staff completed each part of the ACCT process”.
In addition to the evidence heard from the witnesses, I am mindful of the report of HM Chief Inspector of Prisons (Time to care: what helps women cope in prison February 2025) which notes that the rate of self harm among women in prison is now 8.5 times higher than in men’s jails, and highlights a number of issues which continue to this, which have been reflected in this inquest.
” Open source report
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.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
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 Prisons and Probation Ombudsman; 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
10 Jan 2019 Natasha Learline CHIN · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 12 Lack of audit of opiate and alcohol withdrawal observations View source Inadequate training on opiate and alcohol withdrawal signs and dangers View source Failure to make datix referrals for missed medications View source Unclear governance for non-administration of prescribed medication View source Unclear and incomplete protocols for opiate and alcohol withdrawal View source Lack of audit of on-time administration of critical medication View source Lack of verification that medication safety matters have been adequately addressed View source Inadequate training of clinical staff in completing withdrawal scales View source Lack of audit of nurse prescribing and pre-prescription record checks View source Lack of audit of medical-record accuracy on System 1 View source Lack of follow-up and recording of prescribed medication non-attendance View source Lack of medication information sharing with discipline staff View source See 9 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
Natasha Learline CHIN · 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
Natasha Learline Chin died in her cell at HMP Bronzefield on 19 July 2016 after profuse vomiting associated with undertreated opiate and alcohol withdrawal. The report identified concerns about delayed medication, inadequate monitoring and escalation, failures in record-keeping and governance, and insufficient auditing and training.
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 Prisons and Probation Ombudsman; that does not assign responsibility.
PFD Monitor interpretation Lack of audit of opiate and alcohol withdrawal observations
Wider context from the report “1. The prison officer with responsibility for the wing on which Miss Chin was resident was not privy to what medication she was prescribed nor when it should be administered. There is no system in place for consent to be obtained from prisoners for this information to be shared with discipline staff.
2. The Sodexo Justice Service Protocols in respect of opiate and alcohol withdrawal did not adequately mirror the National Protocols and were, in parts, unclear and difficult to comprehend.
3. Nurses failed to make any datix referrals in respect of missed medications.
4. The following matters have to date not been formally audited by Sodexo Justice Services:
i.) Whether prisoners who do not attend for prescribed medications are followed up and the reason for non-attendance is properly recorded.
ii.) Whether critical medication is administered on time.
iii.) Whether proper observations are undertaken in line with national or local protocols in respect of opiate and alcohol withdrawal.
iv.) Whether medical records on System 1 are accurately recorded.
v.) Whether the Patient Guidance Directions in respect of prescribing by nurses are adhered to, and whether medical records are checked before any prescriptions are made by nurses pursuant to the directive.
5. As a consequence it is not possible for Sodexo Justice Services to know whether the matters raised in 4.(i) to (v) have been adequately addressed.
6. The response by Sodexo Justice Services to the issues identified in the report dated the 13th April 2016 of Her Majesty’s Chief Inspector of Prisons in respect of non-administration of prescribed medication was inadequate. It does not appear that there was a clear line of governance in respect of this matter.
7. Whether there is adequate training:
i.) of discipline and clinical staff, including agency staff, to make them aware of the signs and dangers of opiate and alcohol withdrawal.
ii.) of clinical staff in respect of the completion of opiate and alcohol withdrawal scales.
” 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 Prisons and Probation Ombudsman; that does not assign responsibility.
PFD Monitor interpretation Inadequate training on opiate and alcohol withdrawal signs and dangers
Wider context from the report “1. The prison officer with responsibility for the wing on which Miss Chin was resident was not privy to what medication she was prescribed nor when it should be administered. There is no system in place for consent to be obtained from prisoners for this information to be shared with discipline staff.
2. The Sodexo Justice Service Protocols in respect of opiate and alcohol withdrawal did not adequately mirror the National Protocols and were, in parts, unclear and difficult to comprehend.
3. Nurses failed to make any datix referrals in respect of missed medications.
4. The following matters have to date not been formally audited by Sodexo Justice Services:
i.) Whether prisoners who do not attend for prescribed medications are followed up and the reason for non-attendance is properly recorded.
ii.) Whether critical medication is administered on time.
iii.) Whether proper observations are undertaken in line with national or local protocols in respect of opiate and alcohol withdrawal.
iv.) Whether medical records on System 1 are accurately recorded.
v.) Whether the Patient Guidance Directions in respect of prescribing by nurses are adhered to, and whether medical records are checked before any prescriptions are made by nurses pursuant to the directive.
5. As a consequence it is not possible for Sodexo Justice Services to know whether the matters raised in 4.(i) to (v) have been adequately addressed.
6. The response by Sodexo Justice Services to the issues identified in the report dated the 13th April 2016 of Her Majesty’s Chief Inspector of Prisons in respect of non-administration of prescribed medication was inadequate. It does not appear that there was a clear line of governance in respect of this matter.
7. Whether there is adequate training:
i.) of discipline and clinical staff, including agency staff, to make them aware of the signs and dangers of opiate and alcohol withdrawal.
ii.) of clinical staff in respect of the completion of opiate and alcohol withdrawal scales.
” 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 Prisons and Probation Ombudsman; that does not assign responsibility.
PFD Monitor interpretation Failure to make datix referrals for missed medications
Wider context from the report “1. The prison officer with responsibility for the wing on which Miss Chin was resident was not privy to what medication she was prescribed nor when it should be administered. There is no system in place for consent to be obtained from prisoners for this information to be shared with discipline staff.
2. The Sodexo Justice Service Protocols in respect of opiate and alcohol withdrawal did not adequately mirror the National Protocols and were, in parts, unclear and difficult to comprehend.
3. Nurses failed to make any datix referrals in respect of missed medications.
4. The following matters have to date not been formally audited by Sodexo Justice Services:
i.) Whether prisoners who do not attend for prescribed medications are followed up and the reason for non-attendance is properly recorded.
ii.) Whether critical medication is administered on time.
iii.) Whether proper observations are undertaken in line with national or local protocols in respect of opiate and alcohol withdrawal.
iv.) Whether medical records on System 1 are accurately recorded.
v.) Whether the Patient Guidance Directions in respect of prescribing by nurses are adhered to, and whether medical records are checked before any prescriptions are made by nurses pursuant to the directive.
5. As a consequence it is not possible for Sodexo Justice Services to know whether the matters raised in 4.(i) to (v) have been adequately addressed.
6. The response by Sodexo Justice Services to the issues identified in the report dated the 13th April 2016 of Her Majesty’s Chief Inspector of Prisons in respect of non-administration of prescribed medication was inadequate. It does not appear that there was a clear line of governance in respect of this matter.
7. Whether there is adequate training:
i.) of discipline and clinical staff, including agency staff, to make them aware of the signs and dangers of opiate and alcohol withdrawal.
ii.) of clinical staff in respect of the completion of opiate and alcohol withdrawal scales.
” 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 Prisons and Probation Ombudsman; that does not assign responsibility.
PFD Monitor interpretation Unclear governance for non-administration of prescribed medication
Wider context from the report “1. The prison officer with responsibility for the wing on which Miss Chin was resident was not privy to what medication she was prescribed nor when it should be administered. There is no system in place for consent to be obtained from prisoners for this information to be shared with discipline staff.
2. The Sodexo Justice Service Protocols in respect of opiate and alcohol withdrawal did not adequately mirror the National Protocols and were, in parts, unclear and difficult to comprehend.
3. Nurses failed to make any datix referrals in respect of missed medications.
4. The following matters have to date not been formally audited by Sodexo Justice Services:
i.) Whether prisoners who do not attend for prescribed medications are followed up and the reason for non-attendance is properly recorded.
ii.) Whether critical medication is administered on time.
iii.) Whether proper observations are undertaken in line with national or local protocols in respect of opiate and alcohol withdrawal.
iv.) Whether medical records on System 1 are accurately recorded.
v.) Whether the Patient Guidance Directions in respect of prescribing by nurses are adhered to, and whether medical records are checked before any prescriptions are made by nurses pursuant to the directive.
5. As a consequence it is not possible for Sodexo Justice Services to know whether the matters raised in 4.(i) to (v) have been adequately addressed.
6. The response by Sodexo Justice Services to the issues identified in the report dated the 13th April 2016 of Her Majesty’s Chief Inspector of Prisons in respect of non-administration of prescribed medication was inadequate. It does not appear that there was a clear line of governance in respect of this matter.
7. Whether there is adequate training:
i.) of discipline and clinical staff, including agency staff, to make them aware of the signs and dangers of opiate and alcohol withdrawal.
ii.) of clinical staff in respect of the completion of opiate and alcohol withdrawal scales.
” 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 Prisons and Probation Ombudsman; that does not assign responsibility.
PFD Monitor interpretation Unclear and incomplete protocols for opiate and alcohol withdrawal
Wider context from the report “1. The prison officer with responsibility for the wing on which Miss Chin was resident was not privy to what medication she was prescribed nor when it should be administered. There is no system in place for consent to be obtained from prisoners for this information to be shared with discipline staff.
2. The Sodexo Justice Service Protocols in respect of opiate and alcohol withdrawal did not adequately mirror the National Protocols and were, in parts, unclear and difficult to comprehend.
3. Nurses failed to make any datix referrals in respect of missed medications.
4. The following matters have to date not been formally audited by Sodexo Justice Services:
i.) Whether prisoners who do not attend for prescribed medications are followed up and the reason for non-attendance is properly recorded.
ii.) Whether critical medication is administered on time.
iii.) Whether proper observations are undertaken in line with national or local protocols in respect of opiate and alcohol withdrawal.
iv.) Whether medical records on System 1 are accurately recorded.
v.) Whether the Patient Guidance Directions in respect of prescribing by nurses are adhered to, and whether medical records are checked before any prescriptions are made by nurses pursuant to the directive.
5. As a consequence it is not possible for Sodexo Justice Services to know whether the matters raised in 4.(i) to (v) have been adequately addressed.
6. The response by Sodexo Justice Services to the issues identified in the report dated the 13th April 2016 of Her Majesty’s Chief Inspector of Prisons in respect of non-administration of prescribed medication was inadequate. It does not appear that there was a clear line of governance in respect of this matter.
7. Whether there is adequate training:
i.) of discipline and clinical staff, including agency staff, to make them aware of the signs and dangers of opiate and alcohol withdrawal.
ii.) of clinical staff in respect of the completion of opiate and alcohol withdrawal scales.
” 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 Prisons and Probation Ombudsman; that does not assign responsibility.
PFD Monitor interpretation Lack of audit of on-time administration of critical medication
Wider context from the report “1. The prison officer with responsibility for the wing on which Miss Chin was resident was not privy to what medication she was prescribed nor when it should be administered. There is no system in place for consent to be obtained from prisoners for this information to be shared with discipline staff.
2. The Sodexo Justice Service Protocols in respect of opiate and alcohol withdrawal did not adequately mirror the National Protocols and were, in parts, unclear and difficult to comprehend.
3. Nurses failed to make any datix referrals in respect of missed medications.
4. The following matters have to date not been formally audited by Sodexo Justice Services:
i.) Whether prisoners who do not attend for prescribed medications are followed up and the reason for non-attendance is properly recorded.
ii.) Whether critical medication is administered on time.
iii.) Whether proper observations are undertaken in line with national or local protocols in respect of opiate and alcohol withdrawal.
iv.) Whether medical records on System 1 are accurately recorded.
v.) Whether the Patient Guidance Directions in respect of prescribing by nurses are adhered to, and whether medical records are checked before any prescriptions are made by nurses pursuant to the directive.
5. As a consequence it is not possible for Sodexo Justice Services to know whether the matters raised in 4.(i) to (v) have been adequately addressed.
6. The response by Sodexo Justice Services to the issues identified in the report dated the 13th April 2016 of Her Majesty’s Chief Inspector of Prisons in respect of non-administration of prescribed medication was inadequate. It does not appear that there was a clear line of governance in respect of this matter.
7. Whether there is adequate training:
i.) of discipline and clinical staff, including agency staff, to make them aware of the signs and dangers of opiate and alcohol withdrawal.
ii.) of clinical staff in respect of the completion of opiate and alcohol withdrawal scales.
” 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 Prisons and Probation Ombudsman; that does not assign responsibility.
PFD Monitor interpretation Lack of verification that medication safety matters have been adequately addressed
Wider context from the report “1. The prison officer with responsibility for the wing on which Miss Chin was resident was not privy to what medication she was prescribed nor when it should be administered. There is no system in place for consent to be obtained from prisoners for this information to be shared with discipline staff.
2. The Sodexo Justice Service Protocols in respect of opiate and alcohol withdrawal did not adequately mirror the National Protocols and were, in parts, unclear and difficult to comprehend.
3. Nurses failed to make any datix referrals in respect of missed medications.
4. The following matters have to date not been formally audited by Sodexo Justice Services:
i.) Whether prisoners who do not attend for prescribed medications are followed up and the reason for non-attendance is properly recorded.
ii.) Whether critical medication is administered on time.
iii.) Whether proper observations are undertaken in line with national or local protocols in respect of opiate and alcohol withdrawal.
iv.) Whether medical records on System 1 are accurately recorded.
v.) Whether the Patient Guidance Directions in respect of prescribing by nurses are adhered to, and whether medical records are checked before any prescriptions are made by nurses pursuant to the directive.
5. As a consequence it is not possible for Sodexo Justice Services to know whether the matters raised in 4.(i) to (v) have been adequately addressed.
6. The response by Sodexo Justice Services to the issues identified in the report dated the 13th April 2016 of Her Majesty’s Chief Inspector of Prisons in respect of non-administration of prescribed medication was inadequate. It does not appear that there was a clear line of governance in respect of this matter.
7. Whether there is adequate training:
i.) of discipline and clinical staff, including agency staff, to make them aware of the signs and dangers of opiate and alcohol withdrawal.
ii.) of clinical staff in respect of the completion of opiate and alcohol withdrawal scales.
” 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 Prisons and Probation Ombudsman; that does not assign responsibility.
PFD Monitor interpretation Inadequate training of clinical staff in completing withdrawal scales
Wider context from the report “1. The prison officer with responsibility for the wing on which Miss Chin was resident was not privy to what medication she was prescribed nor when it should be administered. There is no system in place for consent to be obtained from prisoners for this information to be shared with discipline staff.
2. The Sodexo Justice Service Protocols in respect of opiate and alcohol withdrawal did not adequately mirror the National Protocols and were, in parts, unclear and difficult to comprehend.
3. Nurses failed to make any datix referrals in respect of missed medications.
4. The following matters have to date not been formally audited by Sodexo Justice Services:
i.) Whether prisoners who do not attend for prescribed medications are followed up and the reason for non-attendance is properly recorded.
ii.) Whether critical medication is administered on time.
iii.) Whether proper observations are undertaken in line with national or local protocols in respect of opiate and alcohol withdrawal.
iv.) Whether medical records on System 1 are accurately recorded.
v.) Whether the Patient Guidance Directions in respect of prescribing by nurses are adhered to, and whether medical records are checked before any prescriptions are made by nurses pursuant to the directive.
5. As a consequence it is not possible for Sodexo Justice Services to know whether the matters raised in 4.(i) to (v) have been adequately addressed.
6. The response by Sodexo Justice Services to the issues identified in the report dated the 13th April 2016 of Her Majesty’s Chief Inspector of Prisons in respect of non-administration of prescribed medication was inadequate. It does not appear that there was a clear line of governance in respect of this matter.
7. Whether there is adequate training:
i.) of discipline and clinical staff, including agency staff, to make them aware of the signs and dangers of opiate and alcohol withdrawal.
ii.) of clinical staff in respect of the completion of opiate and alcohol withdrawal scales.
” 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 Prisons and Probation Ombudsman; that does not assign responsibility.
PFD Monitor interpretation Lack of audit of nurse prescribing and pre-prescription record checks
Wider context from the report “1. The prison officer with responsibility for the wing on which Miss Chin was resident was not privy to what medication she was prescribed nor when it should be administered. There is no system in place for consent to be obtained from prisoners for this information to be shared with discipline staff.
2. The Sodexo Justice Service Protocols in respect of opiate and alcohol withdrawal did not adequately mirror the National Protocols and were, in parts, unclear and difficult to comprehend.
3. Nurses failed to make any datix referrals in respect of missed medications.
4. The following matters have to date not been formally audited by Sodexo Justice Services:
i.) Whether prisoners who do not attend for prescribed medications are followed up and the reason for non-attendance is properly recorded.
ii.) Whether critical medication is administered on time.
iii.) Whether proper observations are undertaken in line with national or local protocols in respect of opiate and alcohol withdrawal.
iv.) Whether medical records on System 1 are accurately recorded.
v.) Whether the Patient Guidance Directions in respect of prescribing by nurses are adhered to, and whether medical records are checked before any prescriptions are made by nurses pursuant to the directive.
5. As a consequence it is not possible for Sodexo Justice Services to know whether the matters raised in 4.(i) to (v) have been adequately addressed.
6. The response by Sodexo Justice Services to the issues identified in the report dated the 13th April 2016 of Her Majesty’s Chief Inspector of Prisons in respect of non-administration of prescribed medication was inadequate. It does not appear that there was a clear line of governance in respect of this matter.
7. Whether there is adequate training:
i.) of discipline and clinical staff, including agency staff, to make them aware of the signs and dangers of opiate and alcohol withdrawal.
ii.) of clinical staff in respect of the completion of opiate and alcohol withdrawal scales.
” 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 Prisons and Probation Ombudsman; that does not assign responsibility.
PFD Monitor interpretation Lack of audit of medical-record accuracy on System 1
Wider context from the report “1. The prison officer with responsibility for the wing on which Miss Chin was resident was not privy to what medication she was prescribed nor when it should be administered. There is no system in place for consent to be obtained from prisoners for this information to be shared with discipline staff.
2. The Sodexo Justice Service Protocols in respect of opiate and alcohol withdrawal did not adequately mirror the National Protocols and were, in parts, unclear and difficult to comprehend.
3. Nurses failed to make any datix referrals in respect of missed medications.
4. The following matters have to date not been formally audited by Sodexo Justice Services:
i.) Whether prisoners who do not attend for prescribed medications are followed up and the reason for non-attendance is properly recorded.
ii.) Whether critical medication is administered on time.
iii.) Whether proper observations are undertaken in line with national or local protocols in respect of opiate and alcohol withdrawal.
iv.) Whether medical records on System 1 are accurately recorded.
v.) Whether the Patient Guidance Directions in respect of prescribing by nurses are adhered to, and whether medical records are checked before any prescriptions are made by nurses pursuant to the directive.
5. As a consequence it is not possible for Sodexo Justice Services to know whether the matters raised in 4.(i) to (v) have been adequately addressed.
6. The response by Sodexo Justice Services to the issues identified in the report dated the 13th April 2016 of Her Majesty’s Chief Inspector of Prisons in respect of non-administration of prescribed medication was inadequate. It does not appear that there was a clear line of governance in respect of this matter.
7. Whether there is adequate training:
i.) of discipline and clinical staff, including agency staff, to make them aware of the signs and dangers of opiate and alcohol withdrawal.
ii.) of clinical staff in respect of the completion of opiate and alcohol withdrawal scales.
” 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 Prisons and Probation Ombudsman; that does not assign responsibility.
PFD Monitor interpretation Lack of follow-up and recording of prescribed medication non-attendance
Wider context from the report “1. The prison officer with responsibility for the wing on which Miss Chin was resident was not privy to what medication she was prescribed nor when it should be administered. There is no system in place for consent to be obtained from prisoners for this information to be shared with discipline staff.
2. The Sodexo Justice Service Protocols in respect of opiate and alcohol withdrawal did not adequately mirror the National Protocols and were, in parts, unclear and difficult to comprehend.
3. Nurses failed to make any datix referrals in respect of missed medications.
4. The following matters have to date not been formally audited by Sodexo Justice Services:
i.) Whether prisoners who do not attend for prescribed medications are followed up and the reason for non-attendance is properly recorded.
ii.) Whether critical medication is administered on time.
iii.) Whether proper observations are undertaken in line with national or local protocols in respect of opiate and alcohol withdrawal.
iv.) Whether medical records on System 1 are accurately recorded.
v.) Whether the Patient Guidance Directions in respect of prescribing by nurses are adhered to, and whether medical records are checked before any prescriptions are made by nurses pursuant to the directive.
5. As a consequence it is not possible for Sodexo Justice Services to know whether the matters raised in 4.(i) to (v) have been adequately addressed.
6. The response by Sodexo Justice Services to the issues identified in the report dated the 13th April 2016 of Her Majesty’s Chief Inspector of Prisons in respect of non-administration of prescribed medication was inadequate. It does not appear that there was a clear line of governance in respect of this matter.
7. Whether there is adequate training:
i.) of discipline and clinical staff, including agency staff, to make them aware of the signs and dangers of opiate and alcohol withdrawal.
ii.) of clinical staff in respect of the completion of opiate and alcohol withdrawal scales.
” 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 Prisons and Probation Ombudsman; that does not assign responsibility.
PFD Monitor interpretation Lack of medication information sharing with discipline staff
Wider context from the report “1. The prison officer with responsibility for the wing on which Miss Chin was resident was not privy to what medication she was prescribed nor when it should be administered. There is no system in place for consent to be obtained from prisoners for this information to be shared with discipline staff.
2. The Sodexo Justice Service Protocols in respect of opiate and alcohol withdrawal did not adequately mirror the National Protocols and were, in parts, unclear and difficult to comprehend.
3. Nurses failed to make any datix referrals in respect of missed medications.
4. The following matters have to date not been formally audited by Sodexo Justice Services:
i.) Whether prisoners who do not attend for prescribed medications are followed up and the reason for non-attendance is properly recorded.
ii.) Whether critical medication is administered on time.
iii.) Whether proper observations are undertaken in line with national or local protocols in respect of opiate and alcohol withdrawal.
iv.) Whether medical records on System 1 are accurately recorded.
v.) Whether the Patient Guidance Directions in respect of prescribing by nurses are adhered to, and whether medical records are checked before any prescriptions are made by nurses pursuant to the directive.
5. As a consequence it is not possible for Sodexo Justice Services to know whether the matters raised in 4.(i) to (v) have been adequately addressed.
6. The response by Sodexo Justice Services to the issues identified in the report dated the 13th April 2016 of Her Majesty’s Chief Inspector of Prisons in respect of non-administration of prescribed medication was inadequate. It does not appear that there was a clear line of governance in respect of this matter.
7. Whether there is adequate training:
i.) of discipline and clinical staff, including agency staff, to make them aware of the signs and dangers of opiate and alcohol withdrawal.
ii.) of clinical staff in respect of the completion of opiate and alcohol withdrawal scales.
” Open source report
13 Dec 2016 Simon John Turvey · Prevention of Future Deaths report Milton Keynes
View report summary
Concerns raised 1 Failure to provide cause for concern line details to visitors and family members 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
Simon John Turvey · 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
Simon John Turvey was found hanging in his locked cell at HMP Woodhill on 29 December 2015 and was declared dead by paramedics. The concerns included failures in the Personal Officer scheme and a lack of proactive communication to family members about how to share concerns with the prison, meaning risk factors may have been missed.
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 Prisons and Probation Ombudsman; that does not assign responsibility.
PFD Monitor interpretation Failure to provide cause for concern line details to visitors and family members
Wider context from the report “1. That the details of the cause for concern line should be given to all visitor and family members so that they can easily report their concerns to the prison.
” Open source report
16 Mar 2016 Steven James May · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 10 Inadequate First Aid training for prison staff View source Selective emergency First Aid training among prison staff View source Lack of mental health experience and/or training among reception nursing staff View source Involvement of prison staff lacking relevant training or appropriate rank in the ACCT process View source Hesitancy to enter a cell during an emergency because of an instruction not to enter cells alone View source Failure to ensure medical professional attendance at First Care Reviews View source Failure of reception nursing staff to consult historical medical notes during reception interviews View source Limited accessibility of health and/or mental health care during weekends and Bank Holidays View source Reliance on verbal handovers rather than written records for prisoner information View source Failure to prepare sufficiently full ACCT assessment notes View source See 7 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
Steven James May · 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
Steven James May died by hanging at HMP Ranby on 25 May 2015 at 01:45, after previously expressing suicidal intent and being placed on the ACCT programme. The report identified concerns about failures in reception health screening, ACCT documentation and reviews, information handovers, staff training and involvement, emergency first aid, cell-entry procedures, and access to health and mental health care.
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 Prisons and Probation Ombudsman; that does not assign responsibility.
PFD Monitor interpretation Inadequate First Aid training for prison staff
Wider context from the report “(9) The inadequacy of First Aid training provided to prison staff in any event (namely, the administration of CPR by prison staff whilst the deceased was lying on a bed );
” 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 Prisons and Probation Ombudsman; that does not assign responsibility.
PFD Monitor interpretation Selective emergency First Aid training among prison staff
Wider context from the report “(7) The selective training of prison staff in emergency First Aid (namely the first member of prison staff on the scene of the death was not trained in the administration of CPR and was ignorant of the location of and method of use of defibrillators );
” 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 Prisons and Probation Ombudsman; that does not assign responsibility.
PFD Monitor interpretation Lack of mental health experience and/or training among reception nursing staff
Wider context from the report “(2) The lack of experience and/or training of reception nursing staff in the field of mental health ;
” 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 Prisons and Probation Ombudsman; that does not assign responsibility.
PFD Monitor interpretation Involvement of prison staff lacking relevant training or appropriate rank in the ACCT process
Wider context from the report “(5) The involvement in the ACCT process of prison staff possessing neither relevant training nor the appropriate rank ;
” 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 Prisons and Probation Ombudsman; that does not assign responsibility.
PFD Monitor interpretation Hesitancy to enter a cell during an emergency because of an instruction not to enter cells alone
Wider context from the report “(8) The hesitancy of the first member of prison staff on the scene to enter the deceased’s cell in apparent adherence to an instruction not to enter cells alone ;
” 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 Prisons and Probation Ombudsman; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure medical professional attendance at First Care Reviews
Wider context from the report “(6) The failure of prison staff to ensure the attendance of a medical professional at the First Care Review ;
” 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 Prisons and Probation Ombudsman; that does not assign responsibility.
PFD Monitor interpretation Failure of reception nursing staff to consult historical medical notes during reception interviews
Wider context from the report “(1) The failure of reception nursing staff , by reason of lack of training and/or instruction or lack of staff and/or time , to consult the deceased’s historical medical notes prior to or during the reception interview ;
” 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 Prisons and Probation Ombudsman; that does not assign responsibility.
PFD Monitor interpretation Limited accessibility of health and/or mental health care during weekends and Bank Holidays
Wider context from the report “(10) The accessibility of health and/or mental health care to inmates at weekends and during Bank Holidays .
” 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 Prisons and Probation Ombudsman; that does not assign responsibility.
PFD Monitor interpretation Reliance on verbal handovers rather than written records for prisoner information
Wider context from the report “(4) Reliance by prison staff on verbal and/or oral handovers of information, rather than written records , regarding the deceased ;
” 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 Prisons and Probation Ombudsman; that does not assign responsibility.
PFD Monitor interpretation Failure to prepare sufficiently full ACCT assessment notes
Wider context from the report “(3) The failure of prison staff when preparing the ACCT document to prepare as full a note as possible . For example, to follow the subject areas suggested in the narrative accompanying sections 1-8 of the Assessment Interview ;
” Open source report
17 Dec 2014 Connor Steven Paul SMITH · Prevention of Future Deaths report Liverpool
View report summary
Concerns raised 1 Failure of investigations to verify the accuracy of relevant attendance records 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
Connor Steven Paul 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
Connor Steven Paul Smith, aged 20, died in custody at HMP Altcourse in the early hours of 2 January 2013 after being found hanging from a bed sheet; resuscitation was unsuccessful. The report identifies a concern about the quality of the PPO investigation, because a prison custody officer was recorded as attending a review hearing despite not being present, potentially hindering learning in another case.
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 Prisons and Probation Ombudsman; that does not assign responsibility.
PFD Monitor interpretation Failure of investigations to verify the accuracy of relevant attendance records
Wider context from the report “On the 28th January 2013 the PPO investigator interviewed a PCO with regard to a review hearing under rule 49 - colloquially known as a rule 45 board. The officer was asked about the record of the meeting in which his name had appeared as an attendee. Given the frequency of such meetings the officer could not remember the meeting on the 1st January 2013 but was interviewed about it creating a 15 page transcript. On examination of other witnesses, other documentary evidence and a video of the meeting made it clear that the PCO was not present at the review hearing – his name had been entered on the Segregation Rule 45/Rule 49 Authority for continued segregation before the meeting but he had not been there.
This is an area of concern highlighting the quality of the investigation by the PPO where by such an error could in another case prevent lessons from being learnt.
” Open source report
25 Jun 2014 Wilfred Roy Aspinwall · Prevention of Future Deaths report Liverpool
View report summary
Concerns raised 1 Failure to share PPO reports and Clinical Reviews with prison healthcare providers View source
Responses linked to these concerns
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AI-generated summary
Wilfred Roy Aspinwall · 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
Wilfred Roy Aspinwall was a frail prisoner with several co-morbidities who sustained falls, including a hip fracture, and later died after a gradual deterioration in health on 21 April 2013. The inquest concluded that he died from natural causes. A substantive concern was that the PPO report and Clinical Review had not been shared with the healthcare provider at HMP Liverpool.
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 Prisons and Probation Ombudsman; that does not assign responsibility.
PFD Monitor interpretation Failure to share PPO reports and Clinical Reviews with prison healthcare providers
Wider context from the report “At the inquest hearing it was clear that the PPO report and Clinical Review had not been sent to nor shared with the Healthcare provider at HMP Liverpool . It might be considered good practice for future reports, in all prison fatalities should to be sent to either the head of healthcare and/or the commissioning NHS Trust to ensure that recommendations have an optimal effect.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations