11 Mar 2025 Sean Higgins · Prevention of Future Deaths report Mid Kent and Medway
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Concerns raised 2 Failure to review relevant ongoing records and case notes before risk reviews View source Failure to ensure support plans are started or completed before ACCT closure 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
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 Jul 2024 Benjamin Noah Frances Harrison · Prevention of Future Deaths report Mid Kent and Medway
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Concerns raised 7 Misalignment of healthcare information-sharing policy and staff practice with PSI64/2011 View source Lack of a clear process for sharing and recording healthcare information View source Lack of guidance for escalating and monitoring suspected intoxication View source Reliance on untrained OSG officers to decide whether to monitor or escalate suspected intoxication View source Failure to promptly notify the prison orderly and document suspected intoxication View source Unavailability of in-house healthcare during the night for prisoners suspected to be under the influence View source Failure to brief prison staff about prisoners with medication in possession View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
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 Jan 2023 John Allen Martin HENDERSON · Prevention of Future Deaths report Mid Kent and Medway
View report summary
Concerns raised 3 Failure to provide closer monitoring for prisoners with seizure activity View source Failure to conduct start-of-day prisoner welfare checks View source Lack of a clear process for consent-based disclosure of prisoners' medical information to front line officers 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
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 May 2016 Ronnie Olliffe · Prevention of Future Deaths report Mid Kent and Medway
View report summary
Concerns raised 3 Lack of understanding of the consequences of issuing a Code Blue View source Failure to consider or use an available defibrillator when appropriate View source Failure to issue a Code Blue when appropriate 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
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
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations