Rochester Prison

Justice · Prison or young offender institution

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First report 15 May 2016•Latest report 11 Mar 2025

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports: 4
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

Concerns and recipient responses

Statements from Rochester Prison linked to the concerns in each report. Select any concern, action or position to view the source wording.

11 Mar2025
Mid Kent and Medway
Concerns raised2
1. Failure to review relevant ongoing records and case notes before risk reviews
2. Failure to ensure support plans are started or completed before ACCT closure
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Sean Higgins · 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

Sean Higgins, who was imprisoned at HMP Rochester, had a history of mental health issues and substance abuse and died after a period of deteriorating mental health, medication non-adherence and repeated self-harm concerns. The inquest concluded that his death was suicide. Concerns included failures to follow prison and mental health policies, inadequate review of relevant records and risk, and ACCT support plans being incomplete when the ACCT was closed.

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 Rochester Prison; that does not assign responsibility.
PFD Monitor interpretation
Failure to review relevant ongoing records and case notes before risk reviews
Wider context from the report
“(1) Although HMP Rochester had addressed many of the concerns raised by the PPO in advance of the inquest, evidence was given at the inquest that some officers chairing reviews did not read relevant documentation beyond the last ACCT review prior to the review taking place. Although they additionally looked at the last CSIP review where the processes were running in tandem, they did not read the ongoing record or Nomis case notes and were unable to conduct an accurate assessment of risk as a result ”
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 Rochester Prison; that does not assign responsibility.
PFD Monitor interpretation
Failure to ensure support plans are started or completed before ACCT closure
Wider context from the report
“(2) Some of the officers chairing reviews did not understand how to complete the support plan paperwork such that the ACCT was closed when some of the support plans had not started or had not been completed ”
Open source report
19 Jul2024
Mid Kent and Medway
Concerns raised7
1. Misalignment of healthcare information-sharing policy and staff practice with PSI64/2011
2. Lack of a clear process for sharing and recording healthcare information
3. Lack of guidance for escalating and monitoring suspected intoxication
1. Reliance on untrained OSG officers to decide whether to monitor or escalate suspected intoxication
2. Failure to promptly notify the prison orderly and document suspected intoxication
3. Unavailability of in-house healthcare during the night for prisoners suspected to be under the influence
4. Failure to brief prison staff about prisoners with medication in possession
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Benjamin Noah Frances Harrison · 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

Benjamin Harrison died in HMP Rochester on 9 May 2022 after inhaling fumes from a medication heated with a vape pen. The inquest identified concerns including insufficient overnight healthcare cover, failure to inform the night orderly that he appeared to be under the influence, inadequate guidance for monitoring and escalation, and weaknesses in medication briefing and information sharing.

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 Rochester Prison; that does not assign responsibility.
PFD Monitor interpretation
Misalignment of healthcare information-sharing policy and staff practice with PSI64/2011
Wider context from the report
“(3) In evidence there were discrepancies between the policies in place and the understanding of healthcare staff as to what information could be shared with prison staff and when it should be shared. Some healthcare staff in evidence indicated they would not share information about medication in any circumstances. The healthcare policy and practice of healthcare staff in relation to information sharing does not align with PSI64/2011 that information can be shared without a prisoner's consent if it is considered necessary to protect the individual or anyone else from the risk of death or serious harm. There was no clear process as to how or where the information would be shared and recorded either where a prisoner had consented to information sharing or where consent had not been given but it was nevertheless necessary to share the information. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Rochester Prison; that does not assign responsibility.
PFD Monitor interpretation
Lack of a clear process for sharing and recording healthcare information
Wider context from the report
“(3) In evidence there were discrepancies between the policies in place and the understanding of healthcare staff as to what information could be shared with prison staff and when it should be shared. Some healthcare staff in evidence indicated they would not share information about medication in any circumstances. The healthcare policy and practice of healthcare staff in relation to information sharing does not align with PSI64/2011 that information can be shared without a prisoner's consent if it is considered necessary to protect the individual or anyone else from the risk of death or serious harm. There was no clear process as to how or where the information would be shared and recorded either where a prisoner had consented to information sharing or where consent had not been given but it was nevertheless necessary to share the information. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Rochester Prison; that does not assign responsibility.
PFD Monitor interpretation
Lack of guidance for escalating and monitoring suspected intoxication
Wider context from the report
“(1) Evidence was given by prison staff that it was not uncommon for prisoners to be under the influence of substances, particularly spice at HMP Rochester. During the day when it was suspected that someone was under the influence, healthcare would attend to assess whether medical attention or monitoring was required there was however no access to in house health care during the night state. OSG officers without medical training or knowledge of the prisoner's medical history had to use their own judgement whether to monitor a prisoner or to escalate the matter. The prison orderly was not notified immediately when someone appeared to be under the influence and that the individual was thought to be under the influence was not documented. Prison staff did not have any guidance or policy to assist them as to when to escalate matters or what monitoring should be undertaken and staff did not routinely use the GP on call service for advice. ”
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 Rochester Prison; that does not assign responsibility.
PFD Monitor interpretation
Reliance on untrained OSG officers to decide whether to monitor or escalate suspected intoxication
Wider context from the report
“(1) Evidence was given by prison staff that it was not uncommon for prisoners to be under the influence of substances, particularly spice at HMP Rochester. During the day when it was suspected that someone was under the influence, healthcare would attend to assess whether medical attention or monitoring was required there was however no access to in house health care during the night state. OSG officers without medical training or knowledge of the prisoner's medical history had to use their own judgement whether to monitor a prisoner or to escalate the matter. The prison orderly was not notified immediately when someone appeared to be under the influence and that the individual was thought to be under the influence was not documented. Prison staff did not have any guidance or policy to assist them as to when to escalate matters or what monitoring should be undertaken and staff did not routinely use the GP on call service for advice. ”
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 Rochester Prison; that does not assign responsibility.
PFD Monitor interpretation
Failure to promptly notify the prison orderly and document suspected intoxication
Wider context from the report
“(1) Evidence was given by prison staff that it was not uncommon for prisoners to be under the influence of substances, particularly spice at HMP Rochester. During the day when it was suspected that someone was under the influence, healthcare would attend to assess whether medical attention or monitoring was required there was however no access to in house health care during the night state. OSG officers without medical training or knowledge of the prisoner's medical history had to use their own judgement whether to monitor a prisoner or to escalate the matter. The prison orderly was not notified immediately when someone appeared to be under the influence and that the individual was thought to be under the influence was not documented. Prison staff did not have any guidance or policy to assist them as to when to escalate matters or what monitoring should be undertaken and staff did not routinely use the GP on call service for advice. ”
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 Rochester Prison; that does not assign responsibility.
PFD Monitor interpretation
Unavailability of in-house healthcare during the night for prisoners suspected to be under the influence
Wider context from the report
“(1) Evidence was given by prison staff that it was not uncommon for prisoners to be under the influence of substances, particularly spice at HMP Rochester. During the day when it was suspected that someone was under the influence, healthcare would attend to assess whether medical attention or monitoring was required there was however no access to in house health care during the night state. OSG officers without medical training or knowledge of the prisoner's medical history had to use their own judgement whether to monitor a prisoner or to escalate the matter. The prison orderly was not notified immediately when someone appeared to be under the influence and that the individual was thought to be under the influence was not documented. Prison staff did not have any guidance or policy to assist them as to when to escalate matters or what monitoring should be undertaken and staff did not routinely use the GP on call service for advice. ”
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 Rochester Prison; that does not assign responsibility.
PFD Monitor interpretation
Failure to brief prison staff about prisoners with medication in possession
Wider context from the report
“(2) Prison staff did not receive a briefing about prisoners with medication in possession in accordance with PSI24/2011 ”
Open source report
17 Jan2023
Mid Kent and Medway
Concerns raised3
1. Failure to provide closer monitoring for prisoners with seizure activity
2. Failure to conduct start-of-day prisoner welfare checks
3. Lack of a clear process for consent-based disclosure of prisoners' medical information to front line officers
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

John Allen Martin HENDERSON · 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

John Allen Martin Henderson was found dead in his bunk at HMP Rochester on 27 May 2021. The inquest recorded natural causes, namely ischaemic heart disease, following a fatal haemorrhage into the wall of the left circumflex artery. Concerns included delayed medical investigations, the absence of a welfare check at the start of the day, and a lack of a clear process for sharing relevant medical information with front-line prison staff.

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 Rochester Prison; that does not assign responsibility.
PFD Monitor interpretation
Failure to provide closer monitoring for prisoners with seizure activity
Wider context from the report
“During the course of evidence, I also established that John was not being monitored any more closely than other prisoners due to his seizure activity. That was confirmed by ████████ ████████ in the course of their evidence. They indicated to me that sometimes they will be asked to monitor prisoners more closely but this had not been applied to John. Likewise, nobody had checked the welfare of John at the start of the day on 27 May 2021. ”
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 Rochester Prison; that does not assign responsibility.
PFD Monitor interpretation
Failure to conduct start-of-day prisoner welfare checks
Wider context from the report
“During the course of evidence, I also established that John was not being monitored any more closely than other prisoners due to his seizure activity. That was confirmed by ████████ ████████ in the course of their evidence. They indicated to me that sometimes they will be asked to monitor prisoners more closely but this had not been applied to John. Likewise, nobody had checked the welfare of John at the start of the day on 27 May 2021. ”
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 Rochester Prison; that does not assign responsibility.
PFD Monitor interpretation
Lack of a clear process for consent-based disclosure of prisoners' medical information to front line officers
Wider context from the report
“I asked additional questions of witnesses and asked to have sight of policies and procedures in respect of information sharing protocols and procedures in respect of prisoners with chronic conditions, (be is seizure activity, diabetes, cardiac issues). My concern being that there did not appear to be a clear process for prisoners to consent to disclosure of medical information to front line officers so that they could be made aware that a particular prisoner may be prone to sudden or unexpected medical episodes. My concern was that a prisoner could have a sudden (but perhaps predictable) acute medical episode and front line prison staff may not be made aware of what was causing the issue or how to respond thereto. ”
Open source report
15 May2016
Mid Kent and Medway
Concerns raised3
1. Lack of understanding of the consequences of issuing a Code Blue
2. Failure to consider or use an available defibrillator when appropriate
3. Failure to issue a Code Blue when appropriate
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Ronnie Olliffe · 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

Ronnie Olliffe collapsed in his cell at HMP Rochester on 1 October 2014 and was later confirmed dead at the scene; the medical cause of death was anabolic steroid-related cardiac hypertrophy. Concerns included failures to issue a required Code Blue, inadequate understanding that this would summon an ambulance, and failure to consider or use an available defibrillator.

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 Rochester Prison; that does not assign responsibility.
PFD Monitor interpretation
Lack of understanding of the consequences of issuing a Code Blue
Wider context from the report
“1) there was a failure to issue a Code Blue pursuant to both a local and national policy in circumstances where it was appropriate to do so 2) there was a lack of understanding as to what consequences flowed from the issuing of a Code Blue, namely that an ambulance would be summoned immediately 3) there was a failure to consider or use a defibrillator when it was appropriate to do so and when one was available ”
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 Rochester Prison; that does not assign responsibility.
PFD Monitor interpretation
Failure to consider or use an available defibrillator when appropriate
Wider context from the report
“1) there was a failure to issue a Code Blue pursuant to both a local and national policy in circumstances where it was appropriate to do so 2) there was a lack of understanding as to what consequences flowed from the issuing of a Code Blue, namely that an ambulance would be summoned immediately 3) there was a failure to consider or use a defibrillator when it was appropriate to do so and when one was available ”
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 Rochester Prison; that does not assign responsibility.
PFD Monitor interpretation
Failure to issue a Code Blue when appropriate
Wider context from the report
“1) there was a failure to issue a Code Blue pursuant to both a local and national policy in circumstances where it was appropriate to do so 2) there was a lack of understanding as to what consequences flowed from the issuing of a Code Blue, namely that an ambulance would be summoned immediately 3) there was a failure to consider or use a defibrillator when it was appropriate to do so and when one was available ”
Open source report

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

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised2

Failure to review relevant ongoing records and case notes before risk reviews

Failure to ensure support plans are started or completed before ACCT closure

Concerns raised7

Misalignment of healthcare information-sharing policy and staff practice with PSI64/2011

Lack of a clear process for sharing and recording healthcare information

Lack of guidance for escalating and monitoring suspected intoxication

Reliance on untrained OSG officers to decide whether to monitor or escalate suspected intoxication

Failure to promptly notify the prison orderly and document suspected intoxication

Unavailability of in-house healthcare during the night for prisoners suspected to be under the influence

Failure to brief prison staff about prisoners with medication in possession

Concerns raised3

Failure to provide closer monitoring for prisoners with seizure activity

Failure to conduct start-of-day prisoner welfare checks

Lack of a clear process for consent-based disclosure of prisoners' medical information to front line officers

Concerns raised3

Lack of understanding of the consequences of issuing a Code Blue

Failure to consider or use an available defibrillator when appropriate

Failure to issue a Code Blue when appropriate