20 Feb 2026 Sean Perry WILLIAMS · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 12 Failure of custody nurses to recognise and describe drug withdrawal signs and symptoms View source Inadequate assessment of first aid knowledge and competence View source Failure to provide the transport vehicle location to emergency services View source Failure to assess and record the clinical picture before and after prescribing View source Delays in custody nurse assessment after detention View source Conflicting guidance on driving a casualty directly to hospital View source Delays in opening a detainee cell and administering emergency first aid View source Insufficient emphasis on urgent life-preserving first aid measures View source Failure of transport crew to maintain focus on monitoring and assisting a detainee in distress View source Failure to operate and provide clear guidance on emergency button procedures View source Failure of first aid staff to provide complete resuscitation measures View source Inadequate first aid training for seizures and other emergencies View source See 9 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Sean Perry WILLIAMS · 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 Williams died in the back of a Serco van outside Thames Magistrates’ Court after suffering a fit during transport and then a cardiac arrest. Concerns included gaps in his custody healthcare assessment and treatment, inadequate Serco first-aid training and competence assessment, failure to provide timely first aid, unclear emergency procedures, and insufficient emphasis on preserving life.
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 Serco Group plc; that does not assign responsibility.
PFD Monitor interpretation Failure of custody nurses to recognise and describe drug withdrawal signs and symptoms
Wider context from the report “For the MPS
The MPS had already recognised before inquest that, following Mr Williams’ detention, he was not seen by a custody nurse for 23 hours.
However, there was another sub optimal element of his care that did not appear to have been identified. The custody nurse who reviewed Mr Williams on two separate occasions in the twelve hours immediately before he attended court, did not on the second occasion take any observations of Mr Williams’ vital signs before (or after) prescribing dihydrocodeine, and did not record any part of Mr Williams’ clinical picture. Despite having prescribed dihydrocodeine for drug withdrawal, when giving evidence in court the nurse was unable to describe the signs and symptoms of withdrawal .
For Serco
By 18.11 hours, the Serco van that was transporting Mr Williams had returned to the court car park entrance and the driver had got out of the cab and into the back of the van. At that point, neither the escort nor the driver opened the door to Mr Williams’ cell to administer first aid - at the very least to relieve his slumped, squashed position to try to deal with any potential airway obstruction. At 18.15 hours when he stopped showing any signs of life, they still did not open his door. They only opened his door at 18.23 hours, removing him from the cell at 18.24 hours, and administering chest compressions at 18.25 hours.
The driver did not press the emergency button in the cab to alert the operations control centre of the situation. The Serco crew did call the London Ambulance Service from the van, but were unable to give the postcode of their location.
I put it to the Serco driver that the focus of the two Serco crew members seemed to be on talking to the three other prisoners in their cells, on phone calls, in fact on anything except getting Mr Williams out of his cell to see if the crew could help him. The driver agreed.
The Serco driver eventually administered chest compressions but could not face giving rescue breaths. He seemed to have forgotten that he had a face guard hanging from his belt.
Despite evidence from Serco that they were satisfied with the first aid training that was given to the two officers, the jury found that:
- the Serco first aid training was inadequate;
- it did not include a video of a seizure;
- it did not sufficiently emphasise the urgency of potentially life saving measures such as use of the recovery position;
- the Serco assessment of the first aid knowledge and competence of its staff was inadequate;
- Serco failed to provide clear guidance on the emergency button procedures;
- Serco’s policy appeared to conflict with its training slides about whether staff should or are even permitted to drive a casualty direct to hospital;
- Serco gave insufficient emphasis on urgency and the paramount importance of preserving life.
” 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 Serco Group plc; that does not assign responsibility.
PFD Monitor interpretation Inadequate assessment of first aid knowledge and competence
Wider context from the report “For the MPS
The MPS had already recognised before inquest that, following Mr Williams’ detention, he was not seen by a custody nurse for 23 hours.
However, there was another sub optimal element of his care that did not appear to have been identified. The custody nurse who reviewed Mr Williams on two separate occasions in the twelve hours immediately before he attended court, did not on the second occasion take any observations of Mr Williams’ vital signs before (or after) prescribing dihydrocodeine, and did not record any part of Mr Williams’ clinical picture. Despite having prescribed dihydrocodeine for drug withdrawal, when giving evidence in court the nurse was unable to describe the signs and symptoms of withdrawal.
For Serco
By 18.11 hours, the Serco van that was transporting Mr Williams had returned to the court car park entrance and the driver had got out of the cab and into the back of the van. At that point, neither the escort nor the driver opened the door to Mr Williams’ cell to administer first aid - at the very least to relieve his slumped, squashed position to try to deal with any potential airway obstruction. At 18.15 hours when he stopped showing any signs of life, they still did not open his door. They only opened his door at 18.23 hours, removing him from the cell at 18.24 hours, and administering chest compressions at 18.25 hours.
The driver did not press the emergency button in the cab to alert the operations control centre of the situation. The Serco crew did call the London Ambulance Service from the van, but were unable to give the postcode of their location.
I put it to the Serco driver that the focus of the two Serco crew members seemed to be on talking to the three other prisoners in their cells, on phone calls, in fact on anything except getting Mr Williams out of his cell to see if the crew could help him. The driver agreed.
The Serco driver eventually administered chest compressions but could not face giving rescue breaths. He seemed to have forgotten that he had a face guard hanging from his belt.
Despite evidence from Serco that they were satisfied with the first aid training that was given to the two officers, the jury found that:
- the Serco first aid training was inadequate;
- it did not include a video of a seizure;
- it did not sufficiently emphasise the urgency of potentially life saving measures such as use of the recovery position;
- the Serco assessment of the first aid knowledge and competence of its staff was inadequate ;
- Serco failed to provide clear guidance on the emergency button procedures;
- Serco’s policy appeared to conflict with its training slides about whether staff should or are even permitted to drive a casualty direct to hospital;
- Serco gave insufficient emphasis on urgency and the paramount importance of preserving life.
” 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 Serco Group plc; that does not assign responsibility.
PFD Monitor interpretation Failure to provide the transport vehicle location to emergency services
Wider context from the report “For the MPS
The MPS had already recognised before inquest that, following Mr Williams’ detention, he was not seen by a custody nurse for 23 hours.
However, there was another sub optimal element of his care that did not appear to have been identified. The custody nurse who reviewed Mr Williams on two separate occasions in the twelve hours immediately before he attended court, did not on the second occasion take any observations of Mr Williams’ vital signs before (or after) prescribing dihydrocodeine, and did not record any part of Mr Williams’ clinical picture. Despite having prescribed dihydrocodeine for drug withdrawal, when giving evidence in court the nurse was unable to describe the signs and symptoms of withdrawal.
For Serco
By 18.11 hours, the Serco van that was transporting Mr Williams had returned to the court car park entrance and the driver had got out of the cab and into the back of the van. At that point, neither the escort nor the driver opened the door to Mr Williams’ cell to administer first aid - at the very least to relieve his slumped, squashed position to try to deal with any potential airway obstruction. At 18.15 hours when he stopped showing any signs of life, they still did not open his door. They only opened his door at 18.23 hours, removing him from the cell at 18.24 hours, and administering chest compressions at 18.25 hours.
The driver did not press the emergency button in the cab to alert the operations control centre of the situation. The Serco crew did call the London Ambulance Service from the van, but were unable to give the postcode of their location .
I put it to the Serco driver that the focus of the two Serco crew members seemed to be on talking to the three other prisoners in their cells, on phone calls, in fact on anything except getting Mr Williams out of his cell to see if the crew could help him. The driver agreed.
The Serco driver eventually administered chest compressions but could not face giving rescue breaths. He seemed to have forgotten that he had a face guard hanging from his belt.
Despite evidence from Serco that they were satisfied with the first aid training that was given to the two officers, the jury found that:
- the Serco first aid training was inadequate;
- it did not include a video of a seizure;
- it did not sufficiently emphasise the urgency of potentially life saving measures such as use of the recovery position;
- the Serco assessment of the first aid knowledge and competence of its staff was inadequate;
- Serco failed to provide clear guidance on the emergency button procedures;
- Serco’s policy appeared to conflict with its training slides about whether staff should or are even permitted to drive a casualty direct to hospital;
- Serco gave insufficient emphasis on urgency and the paramount importance of preserving life.
” 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 Serco Group plc; that does not assign responsibility.
PFD Monitor interpretation Failure to assess and record the clinical picture before and after prescribing
Wider context from the report “For the MPS
The MPS had already recognised before inquest that, following Mr Williams’ detention, he was not seen by a custody nurse for 23 hours.
However, there was another sub optimal element of his care that did not appear to have been identified. The custody nurse who reviewed Mr Williams on two separate occasions in the twelve hours immediately before he attended court, did not on the second occasion take any observations of Mr Williams’ vital signs before (or after) prescribing dihydrocodeine, and did not record any part of Mr Williams’ clinical picture . Despite having prescribed dihydrocodeine for drug withdrawal, when giving evidence in court the nurse was unable to describe the signs and symptoms of withdrawal.
For Serco
By 18.11 hours, the Serco van that was transporting Mr Williams had returned to the court car park entrance and the driver had got out of the cab and into the back of the van. At that point, neither the escort nor the driver opened the door to Mr Williams’ cell to administer first aid - at the very least to relieve his slumped, squashed position to try to deal with any potential airway obstruction. At 18.15 hours when he stopped showing any signs of life, they still did not open his door. They only opened his door at 18.23 hours, removing him from the cell at 18.24 hours, and administering chest compressions at 18.25 hours.
The driver did not press the emergency button in the cab to alert the operations control centre of the situation. The Serco crew did call the London Ambulance Service from the van, but were unable to give the postcode of their location.
I put it to the Serco driver that the focus of the two Serco crew members seemed to be on talking to the three other prisoners in their cells, on phone calls, in fact on anything except getting Mr Williams out of his cell to see if the crew could help him. The driver agreed.
The Serco driver eventually administered chest compressions but could not face giving rescue breaths. He seemed to have forgotten that he had a face guard hanging from his belt.
Despite evidence from Serco that they were satisfied with the first aid training that was given to the two officers, the jury found that:
- the Serco first aid training was inadequate;
- it did not include a video of a seizure;
- it did not sufficiently emphasise the urgency of potentially life saving measures such as use of the recovery position;
- the Serco assessment of the first aid knowledge and competence of its staff was inadequate;
- Serco failed to provide clear guidance on the emergency button procedures;
- Serco’s policy appeared to conflict with its training slides about whether staff should or are even permitted to drive a casualty direct to hospital;
- Serco gave insufficient emphasis on urgency and the paramount importance of preserving life.
” 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 Serco Group plc; that does not assign responsibility.
PFD Monitor interpretation Delays in custody nurse assessment after detention
Wider context from the report “For the MPS
The MPS had already recognised before inquest that, following Mr Williams’ detention, he was not seen by a custody nurse for 23 hours .
However, there was another sub optimal element of his care that did not appear to have been identified. The custody nurse who reviewed Mr Williams on two separate occasions in the twelve hours immediately before he attended court, did not on the second occasion take any observations of Mr Williams’ vital signs before (or after) prescribing dihydrocodeine, and did not record any part of Mr Williams’ clinical picture. Despite having prescribed dihydrocodeine for drug withdrawal, when giving evidence in court the nurse was unable to describe the signs and symptoms of withdrawal.
For Serco
By 18.11 hours, the Serco van that was transporting Mr Williams had returned to the court car park entrance and the driver had got out of the cab and into the back of the van. At that point, neither the escort nor the driver opened the door to Mr Williams’ cell to administer first aid - at the very least to relieve his slumped, squashed position to try to deal with any potential airway obstruction. At 18.15 hours when he stopped showing any signs of life, they still did not open his door. They only opened his door at 18.23 hours, removing him from the cell at 18.24 hours, and administering chest compressions at 18.25 hours.
The driver did not press the emergency button in the cab to alert the operations control centre of the situation. The Serco crew did call the London Ambulance Service from the van, but were unable to give the postcode of their location.
I put it to the Serco driver that the focus of the two Serco crew members seemed to be on talking to the three other prisoners in their cells, on phone calls, in fact on anything except getting Mr Williams out of his cell to see if the crew could help him. The driver agreed.
The Serco driver eventually administered chest compressions but could not face giving rescue breaths. He seemed to have forgotten that he had a face guard hanging from his belt.
Despite evidence from Serco that they were satisfied with the first aid training that was given to the two officers, the jury found that:
- the Serco first aid training was inadequate;
- it did not include a video of a seizure;
- it did not sufficiently emphasise the urgency of potentially life saving measures such as use of the recovery position;
- the Serco assessment of the first aid knowledge and competence of its staff was inadequate;
- Serco failed to provide clear guidance on the emergency button procedures;
- Serco’s policy appeared to conflict with its training slides about whether staff should or are even permitted to drive a casualty direct to hospital;
- Serco gave insufficient emphasis on urgency and the paramount importance of preserving life.
” 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 Serco Group plc; that does not assign responsibility.
PFD Monitor interpretation Conflicting guidance on driving a casualty directly to hospital
Wider context from the report “For the MPS
The MPS had already recognised before inquest that, following Mr Williams’ detention, he was not seen by a custody nurse for 23 hours.
However, there was another sub optimal element of his care that did not appear to have been identified. The custody nurse who reviewed Mr Williams on two separate occasions in the twelve hours immediately before he attended court, did not on the second occasion take any observations of Mr Williams’ vital signs before (or after) prescribing dihydrocodeine, and did not record any part of Mr Williams’ clinical picture. Despite having prescribed dihydrocodeine for drug withdrawal, when giving evidence in court the nurse was unable to describe the signs and symptoms of withdrawal.
For Serco
By 18.11 hours, the Serco van that was transporting Mr Williams had returned to the court car park entrance and the driver had got out of the cab and into the back of the van. At that point, neither the escort nor the driver opened the door to Mr Williams’ cell to administer first aid - at the very least to relieve his slumped, squashed position to try to deal with any potential airway obstruction. At 18.15 hours when he stopped showing any signs of life, they still did not open his door. They only opened his door at 18.23 hours, removing him from the cell at 18.24 hours, and administering chest compressions at 18.25 hours.
The driver did not press the emergency button in the cab to alert the operations control centre of the situation. The Serco crew did call the London Ambulance Service from the van, but were unable to give the postcode of their location.
I put it to the Serco driver that the focus of the two Serco crew members seemed to be on talking to the three other prisoners in their cells, on phone calls, in fact on anything except getting Mr Williams out of his cell to see if the crew could help him. The driver agreed.
The Serco driver eventually administered chest compressions but could not face giving rescue breaths. He seemed to have forgotten that he had a face guard hanging from his belt.
Despite evidence from Serco that they were satisfied with the first aid training that was given to the two officers, the jury found that:
- the Serco first aid training was inadequate;
- it did not include a video of a seizure;
- it did not sufficiently emphasise the urgency of potentially life saving measures such as use of the recovery position;
- the Serco assessment of the first aid knowledge and competence of its staff was inadequate;
- Serco failed to provide clear guidance on the emergency button procedures;
- Serco’s policy appeared to conflict with its training slides about whether staff should or are even permitted to drive a casualty direct to hospital ;
- Serco gave insufficient emphasis on urgency and the paramount importance of preserving life.
” 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 Serco Group plc; that does not assign responsibility.
PFD Monitor interpretation Delays in opening a detainee cell and administering emergency first aid
Wider context from the report “For the MPS
The MPS had already recognised before inquest that, following Mr Williams’ detention, he was not seen by a custody nurse for 23 hours.
However, there was another sub optimal element of his care that did not appear to have been identified. The custody nurse who reviewed Mr Williams on two separate occasions in the twelve hours immediately before he attended court, did not on the second occasion take any observations of Mr Williams’ vital signs before (or after) prescribing dihydrocodeine, and did not record any part of Mr Williams’ clinical picture. Despite having prescribed dihydrocodeine for drug withdrawal, when giving evidence in court the nurse was unable to describe the signs and symptoms of withdrawal.
For Serco
By 18.11 hours, the Serco van that was transporting Mr Williams had returned to the court car park entrance and the driver had got out of the cab and into the back of the van. At that point, neither the escort nor the driver opened the door to Mr Williams’ cell to administer first aid - at the very least to relieve his slumped, squashed position to try to deal with any potential airway obstruction. At 18.15 hours when he stopped showing any signs of life, they still did not open his door . They only opened his door at 18.23 hours, removing him from the cell at 18.24 hours, and administering chest compressions at 18.25 hours .
The driver did not press the emergency button in the cab to alert the operations control centre of the situation. The Serco crew did call the London Ambulance Service from the van, but were unable to give the postcode of their location.
I put it to the Serco driver that the focus of the two Serco crew members seemed to be on talking to the three other prisoners in their cells, on phone calls, in fact on anything except getting Mr Williams out of his cell to see if the crew could help him. The driver agreed.
The Serco driver eventually administered chest compressions but could not face giving rescue breaths. He seemed to have forgotten that he had a face guard hanging from his belt.
Despite evidence from Serco that they were satisfied with the first aid training that was given to the two officers, the jury found that:
- the Serco first aid training was inadequate;
- it did not include a video of a seizure;
- it did not sufficiently emphasise the urgency of potentially life saving measures such as use of the recovery position;
- the Serco assessment of the first aid knowledge and competence of its staff was inadequate;
- Serco failed to provide clear guidance on the emergency button procedures;
- Serco’s policy appeared to conflict with its training slides about whether staff should or are even permitted to drive a casualty direct to hospital;
- Serco gave insufficient emphasis on urgency and the paramount importance of preserving life.
” 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 Serco Group plc; that does not assign responsibility.
PFD Monitor interpretation Insufficient emphasis on urgent life-preserving first aid measures
Wider context from the report “For the MPS
The MPS had already recognised before inquest that, following Mr Williams’ detention, he was not seen by a custody nurse for 23 hours.
However, there was another sub optimal element of his care that did not appear to have been identified. The custody nurse who reviewed Mr Williams on two separate occasions in the twelve hours immediately before he attended court, did not on the second occasion take any observations of Mr Williams’ vital signs before (or after) prescribing dihydrocodeine, and did not record any part of Mr Williams’ clinical picture. Despite having prescribed dihydrocodeine for drug withdrawal, when giving evidence in court the nurse was unable to describe the signs and symptoms of withdrawal.
For Serco
By 18.11 hours, the Serco van that was transporting Mr Williams had returned to the court car park entrance and the driver had got out of the cab and into the back of the van. At that point, neither the escort nor the driver opened the door to Mr Williams’ cell to administer first aid - at the very least to relieve his slumped, squashed position to try to deal with any potential airway obstruction. At 18.15 hours when he stopped showing any signs of life, they still did not open his door. They only opened his door at 18.23 hours, removing him from the cell at 18.24 hours, and administering chest compressions at 18.25 hours.
The driver did not press the emergency button in the cab to alert the operations control centre of the situation. The Serco crew did call the London Ambulance Service from the van, but were unable to give the postcode of their location.
I put it to the Serco driver that the focus of the two Serco crew members seemed to be on talking to the three other prisoners in their cells, on phone calls, in fact on anything except getting Mr Williams out of his cell to see if the crew could help him. The driver agreed.
The Serco driver eventually administered chest compressions but could not face giving rescue breaths. He seemed to have forgotten that he had a face guard hanging from his belt.
Despite evidence from Serco that they were satisfied with the first aid training that was given to the two officers, the jury found that:
- the Serco first aid training was inadequate;
- it did not include a video of a seizure;
- it did not sufficiently emphasise the urgency of potentially life saving measures such as use of the recovery position ;
- the Serco assessment of the first aid knowledge and competence of its staff was inadequate;
- Serco failed to provide clear guidance on the emergency button procedures;
- Serco’s policy appeared to conflict with its training slides about whether staff should or are even permitted to drive a casualty direct to hospital;
- Serco gave insufficient emphasis on urgency and the paramount importance of preserving life .
” 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 Serco Group plc; that does not assign responsibility.
PFD Monitor interpretation Failure of transport crew to maintain focus on monitoring and assisting a detainee in distress
Wider context from the report “For the MPS
The MPS had already recognised before inquest that, following Mr Williams’ detention, he was not seen by a custody nurse for 23 hours.
However, there was another sub optimal element of his care that did not appear to have been identified. The custody nurse who reviewed Mr Williams on two separate occasions in the twelve hours immediately before he attended court, did not on the second occasion take any observations of Mr Williams’ vital signs before (or after) prescribing dihydrocodeine, and did not record any part of Mr Williams’ clinical picture. Despite having prescribed dihydrocodeine for drug withdrawal, when giving evidence in court the nurse was unable to describe the signs and symptoms of withdrawal.
For Serco
By 18.11 hours, the Serco van that was transporting Mr Williams had returned to the court car park entrance and the driver had got out of the cab and into the back of the van. At that point, neither the escort nor the driver opened the door to Mr Williams’ cell to administer first aid - at the very least to relieve his slumped, squashed position to try to deal with any potential airway obstruction. At 18.15 hours when he stopped showing any signs of life, they still did not open his door. They only opened his door at 18.23 hours, removing him from the cell at 18.24 hours, and administering chest compressions at 18.25 hours.
The driver did not press the emergency button in the cab to alert the operations control centre of the situation. The Serco crew did call the London Ambulance Service from the van, but were unable to give the postcode of their location.
I put it to the Serco driver that the focus of the two Serco crew members seemed to be on talking to the three other prisoners in their cells, on phone calls, in fact on anything except getting Mr Williams out of his cell to see if the crew could help him. The driver agreed.
The Serco driver eventually administered chest compressions but could not face giving rescue breaths. He seemed to have forgotten that he had a face guard hanging from his belt.
Despite evidence from Serco that they were satisfied with the first aid training that was given to the two officers, the jury found that:
- the Serco first aid training was inadequate;
- it did not include a video of a seizure;
- it did not sufficiently emphasise the urgency of potentially life saving measures such as use of the recovery position;
- the Serco assessment of the first aid knowledge and competence of its staff was inadequate;
- Serco failed to provide clear guidance on the emergency button procedures;
- Serco’s policy appeared to conflict with its training slides about whether staff should or are even permitted to drive a casualty direct to hospital;
- Serco gave insufficient emphasis on urgency and the paramount importance of preserving life.
” 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 Serco Group plc; that does not assign responsibility.
PFD Monitor interpretation Failure to operate and provide clear guidance on emergency button procedures
Wider context from the report “For the MPS
The MPS had already recognised before inquest that, following Mr Williams’ detention, he was not seen by a custody nurse for 23 hours.
However, there was another sub optimal element of his care that did not appear to have been identified. The custody nurse who reviewed Mr Williams on two separate occasions in the twelve hours immediately before he attended court, did not on the second occasion take any observations of Mr Williams’ vital signs before (or after) prescribing dihydrocodeine, and did not record any part of Mr Williams’ clinical picture. Despite having prescribed dihydrocodeine for drug withdrawal, when giving evidence in court the nurse was unable to describe the signs and symptoms of withdrawal.
For Serco
By 18.11 hours, the Serco van that was transporting Mr Williams had returned to the court car park entrance and the driver had got out of the cab and into the back of the van. At that point, neither the escort nor the driver opened the door to Mr Williams’ cell to administer first aid - at the very least to relieve his slumped, squashed position to try to deal with any potential airway obstruction. At 18.15 hours when he stopped showing any signs of life, they still did not open his door. They only opened his door at 18.23 hours, removing him from the cell at 18.24 hours, and administering chest compressions at 18.25 hours.
The driver did not press the emergency button in the cab to alert the operations control centre of the situation . The Serco crew did call the London Ambulance Service from the van, but were unable to give the postcode of their location.
I put it to the Serco driver that the focus of the two Serco crew members seemed to be on talking to the three other prisoners in their cells, on phone calls, in fact on anything except getting Mr Williams out of his cell to see if the crew could help him. The driver agreed.
The Serco driver eventually administered chest compressions but could not face giving rescue breaths. He seemed to have forgotten that he had a face guard hanging from his belt.
Despite evidence from Serco that they were satisfied with the first aid training that was given to the two officers, the jury found that:
- the Serco first aid training was inadequate;
- it did not include a video of a seizure;
- it did not sufficiently emphasise the urgency of potentially life saving measures such as use of the recovery position;
- the Serco assessment of the first aid knowledge and competence of its staff was inadequate;
- Serco failed to provide clear guidance on the emergency button procedures ;
- Serco’s policy appeared to conflict with its training slides about whether staff should or are even permitted to drive a casualty direct to hospital;
- Serco gave insufficient emphasis on urgency and the paramount importance of preserving life.
” 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 Serco Group plc; that does not assign responsibility.
PFD Monitor interpretation Failure of first aid staff to provide complete resuscitation measures
Wider context from the report “For the MPS
The MPS had already recognised before inquest that, following Mr Williams’ detention, he was not seen by a custody nurse for 23 hours.
However, there was another sub optimal element of his care that did not appear to have been identified. The custody nurse who reviewed Mr Williams on two separate occasions in the twelve hours immediately before he attended court, did not on the second occasion take any observations of Mr Williams’ vital signs before (or after) prescribing dihydrocodeine, and did not record any part of Mr Williams’ clinical picture. Despite having prescribed dihydrocodeine for drug withdrawal, when giving evidence in court the nurse was unable to describe the signs and symptoms of withdrawal.
For Serco
By 18.11 hours, the Serco van that was transporting Mr Williams had returned to the court car park entrance and the driver had got out of the cab and into the back of the van. At that point, neither the escort nor the driver opened the door to Mr Williams’ cell to administer first aid - at the very least to relieve his slumped, squashed position to try to deal with any potential airway obstruction. At 18.15 hours when he stopped showing any signs of life, they still did not open his door. They only opened his door at 18.23 hours, removing him from the cell at 18.24 hours, and administering chest compressions at 18.25 hours.
The driver did not press the emergency button in the cab to alert the operations control centre of the situation. The Serco crew did call the London Ambulance Service from the van, but were unable to give the postcode of their location.
I put it to the Serco driver that the focus of the two Serco crew members seemed to be on talking to the three other prisoners in their cells, on phone calls, in fact on anything except getting Mr Williams out of his cell to see if the crew could help him. The driver agreed.
The Serco driver eventually administered chest compressions but could not face giving rescue breaths. He seemed to have forgotten that he had a face guard hanging from his belt.
Despite evidence from Serco that they were satisfied with the first aid training that was given to the two officers, the jury found that:
- the Serco first aid training was inadequate;
- it did not include a video of a seizure;
- it did not sufficiently emphasise the urgency of potentially life saving measures such as use of the recovery position;
- the Serco assessment of the first aid knowledge and competence of its staff was inadequate;
- Serco failed to provide clear guidance on the emergency button procedures;
- Serco’s policy appeared to conflict with its training slides about whether staff should or are even permitted to drive a casualty direct to hospital;
- Serco gave insufficient emphasis on urgency and the paramount importance of preserving life.
” 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 Serco Group plc; that does not assign responsibility.
PFD Monitor interpretation Inadequate first aid training for seizures and other emergencies
Wider context from the report “For the MPS
The MPS had already recognised before inquest that, following Mr Williams’ detention, he was not seen by a custody nurse for 23 hours.
However, there was another sub optimal element of his care that did not appear to have been identified. The custody nurse who reviewed Mr Williams on two separate occasions in the twelve hours immediately before he attended court, did not on the second occasion take any observations of Mr Williams’ vital signs before (or after) prescribing dihydrocodeine, and did not record any part of Mr Williams’ clinical picture. Despite having prescribed dihydrocodeine for drug withdrawal, when giving evidence in court the nurse was unable to describe the signs and symptoms of withdrawal.
For Serco
By 18.11 hours, the Serco van that was transporting Mr Williams had returned to the court car park entrance and the driver had got out of the cab and into the back of the van. At that point, neither the escort nor the driver opened the door to Mr Williams’ cell to administer first aid - at the very least to relieve his slumped, squashed position to try to deal with any potential airway obstruction. At 18.15 hours when he stopped showing any signs of life, they still did not open his door. They only opened his door at 18.23 hours, removing him from the cell at 18.24 hours, and administering chest compressions at 18.25 hours.
The driver did not press the emergency button in the cab to alert the operations control centre of the situation. The Serco crew did call the London Ambulance Service from the van, but were unable to give the postcode of their location.
I put it to the Serco driver that the focus of the two Serco crew members seemed to be on talking to the three other prisoners in their cells, on phone calls, in fact on anything except getting Mr Williams out of his cell to see if the crew could help him. The driver agreed.
The Serco driver eventually administered chest compressions but could not face giving rescue breaths. He seemed to have forgotten that he had a face guard hanging from his belt.
Despite evidence from Serco that they were satisfied with the first aid training that was given to the two officers, the jury found that:
- the Serco first aid training was inadequate ;
- it did not include a video of a seizure ;
- it did not sufficiently emphasise the urgency of potentially life saving measures such as use of the recovery position;
- the Serco assessment of the first aid knowledge and competence of its staff was inadequate;
- Serco failed to provide clear guidance on the emergency button procedures;
- Serco’s policy appeared to conflict with its training slides about whether staff should or are even permitted to drive a casualty direct to hospital;
- Serco gave insufficient emphasis on urgency and the paramount importance of preserving life.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise relevant prisoner welfare, vehicle escort, death-in-custody and associated procedures, and align corresponding training materials.
Verbatim wording from the response “Since the death of Mr Williams we have revised Standard Operating Procedure (SOP) 038 Prisoner Welfare on a Vehicle, SOP 009 Duties of a Vehicle Escort Officer and SOP 047 Death or attempted suicide of a prisoner in custody, to improve the clarity of the steps to be taken where a medical emergency is suspected and I understand copies of the updated SOPs have been provided to you. The changes have also been reflected in other SOPs and training documents to ensure consistency.” Source location Response from Serco
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and display an OCC emergency flowchart with structured prompt questions at controller desks to standardise alarm-activation responses.
Verbatim wording from the response “Serco has also developed a corresponding flowchart for the OCC to reflect that provided to PCOs, together with structured prompt questions to assist OCC controllers in identifying the nature of an emergency and providing appropriate support and direction to PCOs when an incident occurs. A copy of the OCC flowchart has also been provided.” Source location Response from Serco
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Create and require staff to complete a separate online medical-emergency vehicle course covering emergency response, basic life support and related vehicle incidents, with an 80% pass threshold.
Verbatim wording from the response “In addition, in order to remind staff of the required process and aid their retention of the information provided during the training, in March 2025 we created a new online course on Serco’s LMS. This is a mandatory course for all staff members and includes what to do in an emergency medical incident, basic life support, self-harm incidents, vehicle breakdown, fire and anything deemed a vehicle emergency. The content provides a refresher of the training covered in the ITC course, to reinforce learning and gives additional prominence by being a separate module and links together the concepts that staff have learned during their Highfield First Aid training.” Source location Response from Serco
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and display laminated emergency-response flowcharts in escort vehicles to clarify required actions and support consistent responses.
Verbatim wording from the response “As outlined by Serco’s Head of Professional Standards and Security in his evidence, and to support staff on scene in following the correct process, Serco has developed a flowchart for escort officers following the death of Mr Williams. A copy appears in the Inquest bundle. This has since been incorporated into training, and laminated copies are now displayed within all escort vehicles in a position visible from the escort seat. The intention is that this readily accessible guide will reinforce existing training, clarify the required steps, and support escort officers in responding with confidence and consistency during suspected medical emergencies.” Source location Response from Serco
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review recovery-position training adequacy and whether additional or new content should be included in the vehicle-emergencies module.
Verbatim wording from the response “I note the jury’s findings and that one particular concern related to seizures. As you will note the First Aid slides include a whole section on seizures (slides 118-122). Nevertheless, while seizure recognition and response forms part of existing first-aid training, this finding has prompted Serco to consider whether additional measures are required to strengthen staff confidence and recognition with respect to this issue in practice. Similarly, the findings relating to the use of the recovery position have informed a focused review of how this aspect of training is emphasised and reinforced. That said, once again, you will have noted that there is a whole section on the recovery position within the training slides (slides 49-57). I can also confirm that aspects of both of these sections are included in the assessment of staff when the training is concluded.” Source location Response from Serco
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review training with Highfield to explore including a seizure video to improve seizure recognition and response retention.
Verbatim wording from the response “We are also in the process of reviewing the training provided with the awarding organisation, Highfield, to explore the possibility of including a video of a seizure in the training, to assist staff in identifying a seizure, and in retaining the instruction provided on how to deal with a seizure should they encounter one. A review of the adequacy of the training on the recovery position is also being undertaken to ascertain that any possible improvements are implemented. We are also reviewing whether it would be appropriate to include additional and new training on the recovery position within the training module on vehicle emergencies, to emphasise its importance, and to assist in retention of this very importance aspect of the training.” Source location Response from Serco
Open published response
9 Feb 2026 Gareth Chumber-Kelly · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 4 Inefficiency and slowness of the prison reception process View source Failure to provide suicide and self-harm risk management training to prison officers View source Failure to provide regular mandatory basic life support training to prison officers View source Failure to retain documentation accompanying prisoners during reception View source See 1 more concern
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
Gareth Chumber-Kelly · 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
Gareth Chumber-Kelly died after hanging himself while in custody at HMP Pentonville on 17 July 2023. The report identified concerns about lost or incomplete transfer documentation, inadequate recognition and management of suicide and self-harm risks, insufficient staff training, failures to provide basic life support, and inadequate staffing and support during crucial periods.
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 Serco Group plc; that does not assign responsibility.
PFD Monitor interpretation Inefficiency and slowness of the prison reception process
Wider context from the report “(1) The court heard evidence from prison staff that the reception process at HMP Pentonville was inefficient and slow and that paperwork would be sometimes be lost. This creates a risk to the safety and well-being of prisoners as the documentation accompanying the prisoner as they are conveyed to prison may contain (as was the case with Mr Chumber-Kelly) very important information about the prisoners which is relevant to ensuring all appropriate steps and measures are put in place to protect them. The Governor at HMP Pentonville told the court that no steps have been taken to address this recurrent problem , and the risk of important documentation being lost, and there has been no dialogue with Serco to address this issue.
” 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 Serco Group plc; that does not assign responsibility.
PFD Monitor interpretation Failure to provide suicide and self-harm risk management training to prison officers
Wider context from the report “(2) The court heard evidence that 2 prisoners had died by ligature suspension (on 17.6.2021 and 1.3.22) prior to Mr Chumber-Kelly’s death, and that since then a further 5 prisoners have died by ligature suspension (one of which was Mr Chumber-Kelly). The Governor of HMP Pentonville told the court that Suicide and Self harm training for prison staff had been suspended during Covid and had never been re-started notwithstanding that 38% of prisoners arriving at HMP Pentonville said they felt suicidal and notwithstanding that 7 prisoners have died by ligature suspension since June 2021. The failure to train prison officers in the risks and management of suicide and self-harm creates a risk of future 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 Serco Group plc; that does not assign responsibility.
PFD Monitor interpretation Failure to provide regular mandatory basic life support training to prison officers
Wider context from the report “(3) The court heard evidence that the first two officers on the scene failed to provide any form of basic life support despite having received training on how to do so. Both officers described how they panicked and did not know what to do. The court heard evidence from a consultant paramedic from the London Ambulance service with extensive experience in resuscitation who explained that for every minute without CPR there is a 10-22% drop in survival rates. It is critically important that the first person on the scene in such emergency situations (who will almost always be the prison officers) are properly and regularly trained in basic life support so that they are able to render such aid immediately on arrival. The Governor of the prison told the court that no refresher CPR training had been provided to prison staff since 2023 notwithstanding the 5 deaths of prisoners by ligature suspension that have occurred since. This is deeply concerning given that this very same issue was raised in a Prevention of Future Deaths Report by Mary Hassell, HM Senior Coroner of Inner North London on 18th September 2023 relating to the death of Amarjit Singh and yet in the 2 years since that PFD was issued there is still no mandatory basic life support training for prison officers .
The failure of the prison to provide regular, mandatory basic life support to all prison officer creates a risk of future 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 Serco Group plc; that does not assign responsibility.
PFD Monitor interpretation Failure to retain documentation accompanying prisoners during reception
Wider context from the report “(1) The court heard evidence from prison staff that the reception process at HMP Pentonville was inefficient and slow and that paperwork would be sometimes be lost . This creates a risk to the safety and well-being of prisoners as the documentation accompanying the prisoner as they are conveyed to prison may contain (as was the case with Mr Chumber-Kelly) very important information about the prisoners which is relevant to ensuring all appropriate steps and measures are put in place to protect them. The Governor at HMP Pentonville told the court that no steps have been taken to address this recurrent problem, and the risk of important documentation being lost , and there has been no dialogue with Serco to address this issue.
” Open source report
7 Feb 2025 Anthony Binfield and 2 others · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 14 Inadequate basic training, supervision and mentoring of prison staff View source Inadequate prison and healthcare staffing levels View source Failure to act with candour in post-death investigations View source Use of inaccessible email channels for risk pertinent information View source Failure to identify and share risk pertinent information between prison and healthcare staff View source Insufficient safety scrutiny during prison contract transfer View source Failure to reduce isolation of foreign national prisoners View source Failure to embed learning from deaths and monitor safety culture View source Failure to provide a nurse during night state View source Unreliable and delayed access to interpretation services for foreign national prisoners View source Lack of an effective system for gathering, retaining, reviewing and disclosing investigation material View source Failure to retain sufficient experienced prison and healthcare staff View source Lack of effective NPS-specific drug policy View source Lack of a formal prison-to-prison transfer management system View source See 11 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
Anthony Binfield and 2 others · 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
Anthony Binfield, David William Richards and Rolandas Karbauskas died at HMP Lowdham Grange in March 2023 after using ligatures; Anthony’s and Rolandas’s deaths were suicides, while David’s death was accidental. The report identified missed opportunities to recognise and share risk information, shortcomings in prison and healthcare staffing, training and systems, and concerns about prisoner transfers, isolation, the prison contract transfer, and learning from previous deaths.
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 Serco Group plc; that does not assign responsibility.
PFD Monitor interpretation Inadequate basic training, supervision and mentoring of prison staff
Wider context from the report “All of the prison staff had completed the ITC programme, and yet there was widespread evidence of failures to do the basics . Staff failed to ensure the welfare of prisoners at roll count, failed to challenge flagrant breaches of Prison rules such as passing items under cell doors, and did not know how to properly deal with obscured cell observation hatches.
This calls into question the adequacy of their basic training, and the system for supervision and mentoring during the early years of practice.
” 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 Serco Group plc; that does not assign responsibility.
PFD Monitor interpretation Inadequate prison and healthcare staffing levels
Wider context from the report “The inadequate prison and healthcare staffing levels led to a restricted regime and healthcare provision. The prison was unable to offer keywork to all men, and the mental health team could no longer offer a named nurse service. Both of these aspects of care are fundamental to supporting the most vulnerable prisoners.
” 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 Serco Group plc; that does not assign responsibility.
PFD Monitor interpretation Failure to act with candour in post-death investigations
Wider context from the report “The Healthcare Trust are subject to a statutory duty of candour. HMPPS, Serco and Sodexo failed to embrace the same ethos during these investigations.
” 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 Serco Group plc; that does not assign responsibility.
PFD Monitor interpretation Use of inaccessible email channels for risk pertinent information
Wider context from the report “I am also concerned by the use of email to convey risk pertinent information . In this case, prison staff communicated their concerns about Anthony’s mental health to individual nursing Sodexo email inboxes, which the nurses were not expected to regularly access . The use of email means that such concerns are not accessible to other members of staff as they would be if they were recorded in PNOMIS or Systemone.
” 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 Serco Group plc; that does not assign responsibility.
PFD Monitor interpretation Failure to identify and share risk pertinent information between prison and healthcare staff
Wider context from the report “There was a complete breakdown in the system of risk identification and information sharing . Prison and healthcare staff did not routinely consider information captured within the electronic systems , nor did they update the systems with risk pertinent information gathered during interactions with the prisoners .
” 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 Serco Group plc; that does not assign responsibility.
PFD Monitor interpretation Insufficient safety scrutiny during prison contract transfer
Wider context from the report “Safety was not front and centre of the Mobilisation and Transfer project.
” 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 Serco Group plc; that does not assign responsibility.
PFD Monitor interpretation Failure to reduce isolation of foreign national prisoners
Wider context from the report “I heard evidence that the Big Word translation service did not work on multiple occasions across multiple sites within the prison. Staff gave evidence that even when the system did connect, they could be waiting in a queue for up to an hour to access an appropriate interpreter.
There was no plan to seek to reduce Rolandas’ obvious isolation , and seemingly no provision for expediting his induction so that he could be housed with fellow Lithuanian speakers .
” 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 Serco Group plc; that does not assign responsibility.
PFD Monitor interpretation Failure to embed learning from deaths and monitor safety culture
Wider context from the report “I heard evidence that many of the contributory factors leading to the deaths of Anthony, David and Rolandas, had been raised as issues in the investigations following previous deaths in custody at HMP Lowdham Grange.
While Serco no longer manage HMP Lowdham Grange, they continue to manage prisons, and there is a risk of future deaths if the organisation is unable to create a robust culture of seeking to identify issues early, adopt learning, and continually monitor culture to ensure any action taken is embedded to reduce the risk of future 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 Serco Group plc; that does not assign responsibility.
PFD Monitor interpretation Failure to provide a nurse during night state
Wider context from the report “For months prior to the deaths, the Trust failed to fulfil its commissioned obligations to provide a nurse during night state . Prison staff have only basic first aid training and lacked the expertise of a medical professional when attempting to provide CPR to Anthony.
” 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 Serco Group plc; that does not assign responsibility.
PFD Monitor interpretation Unreliable and delayed access to interpretation services for foreign national prisoners
Wider context from the report “I heard evidence that the Big Word translation service did not work on multiple occasions across multiple sites within the prison . Staff gave evidence that even when the system did connect, they could be waiting in a queue for up to an hour to access an appropriate interpreter .
There was no plan to seek to reduce Rolandas’ obvious isolation, and seemingly no provision for expediting his induction so that he could be housed with fellow Lithuanian speakers.
” 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 Serco Group plc; that does not assign responsibility.
PFD Monitor interpretation Lack of an effective system for gathering, retaining, reviewing and disclosing investigation material
Wider context from the report “HMPPS have no effective system for gathering, retaining, reviewing and disclosing potentially relevant material so that the issues relevant to death can be identified and learning put in place.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Serco Group plc; that does not assign responsibility.
PFD Monitor interpretation Failure to retain sufficient experienced prison and healthcare staff
Wider context from the report “I am concerned by the failure to retain experienced prison officers and healthcare staff . The private prison operator and the Authority were focused on the number of staff, rather than the skill sets or experience of the staffing body as a whole .
” 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 Serco Group plc; that does not assign responsibility.
PFD Monitor interpretation Lack of effective NPS-specific drug policy
Wider context from the report “There is no requirement for prisons to have an NPS specific drug policy and I am concerned that generic drug reduction strategies are ineffective against this particular threat .
NPS is highly dangerous and carries a risk of death. I am concerned that more young men will die in custody as a result of NPS use.
” 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 Serco Group plc; that does not assign responsibility.
PFD Monitor interpretation Lack of a formal prison-to-prison transfer management system
Wider context from the report “I heard evidence that there is no formal policy framework or system for managing the progress of prison-to-prison transfers , including a lack of expected response times or formal escalation plan if a prison fails to provide any response.
” Open source report
8 Nov 2016 Ms Michelle Ann Lawrence · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 6 Insufficient CCTV-monitoring facilities for detainees at risk in custody View source Insufficient PNC character capacity for meaningful risk recording View source Lack of independent investigation into deaths following release from private custody providers View source Failure to ask detainees about concealment View source Unavailability of strip-search facilities in SERCO custody View source Failure to routinely check toilets for concealed items after detainee use View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Ms Michelle Ann Lawrence · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Ms Michelle Ann Lawrence died at home on 2 May 2015 from respiratory failure after taking multiple prescription and illegal sedative drugs, following periods in police and private custody. The principal concerns included failures to identify concealed drugs, limited strip-searching and CCTV facilities, inadequate checking of custody-suite toilets, insufficient detail in risk records, and the lack of independent investigation into deaths following release from private custody providers.
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 Serco Group plc; that does not assign responsibility.
PFD Monitor interpretation Insufficient CCTV-monitoring facilities for detainees at risk in custody
Wider context from the report “(5) That all custody suites have sufficient facilities for CCTV monitoring of detainees at risk in custody whether held by the State or private custody providers.
” 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 Serco Group plc; that does not assign responsibility.
PFD Monitor interpretation Insufficient PNC character capacity for meaningful risk recording
Wider context from the report “(6) That the number of characters on the PNC where risks are described and highlighted need to be increased to allow sufficient meaningful detail to be recorded to allow accurate risk assessment by staff without having to trawl through multiple electronic documents .
” 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 Serco Group plc; that does not assign responsibility.
PFD Monitor interpretation Lack of independent investigation into deaths following release from private custody providers
Wider context from the report “(1) That there is no independent investigation into the deaths of persons following release from private providers of custody analogous to the IPCC such that important evidence is lost that upon analysis may be used to learn lessons and thus prevent future 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 Serco Group plc; that does not assign responsibility.
PFD Monitor interpretation Failure to ask detainees about concealment
Wider context from the report “(2) That detainees are currently not asked about concealment . Such questions at booking in by police and on transfer between custody providers and when in consultation with health care professionals would provide an opportunity for some individuals who conceal to be identified either by positive responses to such questions or by allowing staff to assess their credibility. Ms Lawrence had admitted to taking drugs whilst in custody in February 2015.
” 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 Serco Group plc; that does not assign responsibility.
PFD Monitor interpretation Unavailability of strip-search facilities in SERCO custody
Wider context from the report “(3) That facilities for strip searching appear to be virtually non-existent for those in the custody of SERCO.
” 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 Serco Group plc; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely check toilets for concealed items after detainee use
Wider context from the report “(4) That SERCO staff do not appear to routinely check toilets for concealed items after they have been used by detainees .
” Open source report
Concerns raised 2 Failure to ensure Code Blue responders know where to go View source Insufficient availability of recently CPR-trained Prison Officers for emergencies 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
DARREN WRIGHT · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Darren Wright, aged 35, was found dead in his cell at HMP Norwich on 3 November 2013 after having been admitted to prison in September 2013. The report identified concerns about inconsistent sharing and access to information, the response to a Code Blue notification, and gaps in recent CPR training among attending prison officers.
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 Serco Group plc; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure Code Blue responders know where to go
Wider context from the report “(1) On receiving Code Blue notification the Staff Nurse did not know where to go and had to call on her radio to be found and then taken to the cell ;
” 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 Serco Group plc; that does not assign responsibility.
PFD Monitor interpretation Insufficient availability of recently CPR-trained Prison Officers for emergencies
Wider context from the report “(2) The Prison Officers attending Mr Wright had not had recent CPR training . It is understood that due to a lack of resources, CPR training has had to be allocated to certain members of staff only . This will result in gaps in CPR-trained Officers available and able to attend emergencies .
” Open source report
18 Sep 2014 Brian Christopher Dalrymple · Prevention of Future Deaths report West London
View report summary
Concerns raised 6 Absence of a comprehensive and accessible computerised clinical record for each detainee View source Employment of medical practitioners without knowledge necessary to their role View source Inadequate routine medical assessment of segregated detainees View source Lack of detention staff awareness and recognition of mental-health indicators View source Failure to actively communicate relevant observations to healthcare staff View source Failure to bring potential mental-health indicators to responsible healthcare staff View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Brian Christopher Dalrymple · 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
Brian Christopher Dalrymple died at Colnbrook Immigration Removal Centre on 31 July 2011 after a fatal rupture associated with extreme hypertension, which he declined to have treated and monitored for most of his detention. The report raised concerns that indicators of his deteriorating mental health were not recognised or communicated to healthcare staff, that medical practitioners lacked necessary knowledge, that medical visits to segregated detainees were inadequate, and that clinical records were not comprehensive or accessible.
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 Serco Group plc; that does not assign responsibility.
PFD Monitor interpretation Absence of a comprehensive and accessible computerised clinical record for each detainee
Wider context from the report “(5)
The absence of a comprehensive and accessible (computerised) clinical record relating to each detainee at IRCs Harmondsworth and Colnbrook.
” 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 Serco Group plc; that does not assign responsibility.
PFD Monitor interpretation Employment of medical practitioners without knowledge necessary to their role
Wider context from the report “(3)
Medical practitioners may be employed at Harmondsworth IRC without knowledge necessary to that role.
The locum GP who gave evidence at the inquest was unaware of Detention Centre Rules 2001 or of the duties imposed on him- rule 35, for example. He was also unaware that healthcare staff had access to wing history documents.
” 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 Serco Group plc; that does not assign responsibility.
PFD Monitor interpretation Inadequate routine medical assessment of segregated detainees
Wider context from the report “(4)
Routine medical visits to segregated detainees are inadequate properly to assess detainees' healthcare needs.
The evidence was that each detainee would be asked through the wicket “Any medical problems?”, and if the answer was negative, there would be no further interaction- witness ████████ described the practice as “not fit for purpose” ;
” 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 Serco Group plc; that does not assign responsibility.
PFD Monitor interpretation Lack of detention staff awareness and recognition of mental-health indicators
Wider context from the report “(1)
There is a lack of awareness amongst detention staff at Harmondsworth of: (i) behaviours (and reported experiences) which may indicate the existence of mental health issues affecting particular detainees- particularly in relation to schizophrenia ; and (ii) the need to ensure that such potential indicators are brought to the attention of those responsible for the particular detainee's healthcare.
Despite the training which had been received by such staff prior to Mr Dalrymple's detention, indications of his mental ill-health were not recognised as such. Witness ████████ identified events and circumstances from the point of Mr Dalrymple's presentation at port and throughout his period of detention that he said “should have been picked up” and triggered a psychiatric assessment (for which there was an “overwhelming need”). In Mr Dalrymple's case such concerns were not properly acknowledged at Harmondsworth.
The DCOs had not received sufficient training in the recognition of relevant indicators. The evidence was that officers were and remain unclear whether particular behaviours, unusual in local society at large, should be regarded as significant amongst the population at Harmondsworth.
It was clear from the evidence given by the Deputy Immigration Manager, and that of a clinical Contract Manager / Interim Healthcare Manager that significant reliance is placed on the detention officers to raise concerns over a detainee's mental heath.
” 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 Serco Group plc; that does not assign responsibility.
PFD Monitor interpretation Failure to actively communicate relevant observations to healthcare staff
Wider context from the report “(2)
Relevant and significant observations recorded by detention centre staff and others are not actively brought to the attention of relevant healthcare staff.
In the present case, custody officers' entries in wing history records were sufficient (alone or in combination) to alert a reader to the possibility of mental health issues affecting Mr Dalrymple whilst detained at Harmondsworth IRC; these indicators were missed. In the terms of Witness ████████ the overall picture of developing (relapsing) mental disorder was not available to any one set of people.
” 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 Serco Group plc; that does not assign responsibility.
PFD Monitor interpretation Failure to bring potential mental-health indicators to responsible healthcare staff
Wider context from the report “(1)
There is a lack of awareness amongst detention staff at Harmondsworth of: (i) behaviours (and reported experiences) which may indicate the existence of mental health issues affecting particular detainees- particularly in relation to schizophrenia; and (ii) the need to ensure that such potential indicators are brought to the attention of those responsible for the particular detainee's healthcare.
Despite the training which had been received by such staff prior to Mr Dalrymple's detention, indications of his mental ill-health were not recognised as such. Witness ████████ identified events and circumstances from the point of Mr Dalrymple's presentation at port and throughout his period of detention that he said “should have been picked up” and triggered a psychiatric assessment (for which there was an “overwhelming need”). In Mr Dalrymple's case such concerns were not properly acknowledged at Harmondsworth.
The DCOs had not received sufficient training in the recognition of relevant indicators. The evidence was that officers were and remain unclear whether particular behaviours, unusual in local society at large, should be regarded as significant amongst the population at Harmondsworth.
It was clear from the evidence given by the Deputy Immigration Manager, and that of a clinical Contract Manager / Interim Healthcare Manager that significant reliance is placed on the detention officers to raise concerns over a detainee's mental heath.
” Open source report
3 Mar 2014 Lee Sean MACPHERSON · Prevention of Future Deaths report West London
View report summary
Concerns raised 4 Failure to complete escort handover details on the PER View source Failure to ensure that police documentation recorded as accompanying the PER is available to escort staff View source Lack of shared understanding about police documentation accompanying persons in custody View source Failure to complete and provide the police risk assessment before custody escort View source See 1 more concern
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
Lee Sean MACPHERSON · 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
Lee Sean MACPHERSON was found dead in a safer custody cell at HMP Wormwood Scrubs on 17 October 2012, after being remanded into custody the previous afternoon. Concerns related to incomplete and inconsistently transferred police risk-assessment and escort handover documentation between the police, SERCO and 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 Serco Group plc; that does not assign responsibility.
PFD Monitor interpretation Failure to complete escort handover details on the PER
Wider context from the report “(3) The escort handover details on the PER were not completed by the prison staff (or SERCO staff which is a matter SERCO have already addressed).
” 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 Serco Group plc; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure that police documentation recorded as accompanying the PER is available to escort staff
Wider context from the report “(2) There was a lack of common understanding between SERCO staff and prison staff about what police documentation, including the police risk assessment, accompanied a person in custody, in addition to the PER. Boxes on the PER had been ticked indicating that, among other things, it was accompanied by a police risk assessment but SERCO staff said they had not seen that or the other documents .
” 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 Serco Group plc; that does not assign responsibility.
PFD Monitor interpretation Lack of shared understanding about police documentation accompanying persons in custody
Wider context from the report “(2) There was a lack of common understanding between SERCO staff and prison staff about what police documentation, including the police risk assessment, accompanied a person in custody, in addition to the PER. Boxes on the PER had been ticked indicating that, among other things, it was accompanied by a police risk assessment but SERCO staff said they had not seen that or the other documents .
” 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 Serco Group plc; that does not assign responsibility.
PFD Monitor interpretation Failure to complete and provide the police risk assessment before custody escort
Wider context from the report “(1) The police risk assessment was not completed until the deceased had already been collected by SERCO and it was a police risk assessment completed in the early hours of the morning that found its way to the prison .
” Open source report
9 Aug 2013 Ronald Sherlock · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 1 Lack of appropriate access to speech and language therapist assessment and medical management recommendations for prisoners with swallowing difficulties 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
Ronald Sherlock · 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 Sherlock, a 92-year-old prisoner at HM Prison Norwich, was found unresponsive in his cell on 24 April 2012 and could not be revived. The report raised concern that prisoners in the Older Prisoners Unit did not have appropriate access to speech and language therapists for assessment and management of swallowing difficulties.
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 Serco Group plc; that does not assign responsibility.
PFD Monitor interpretation Lack of appropriate access to speech and language therapist assessment and medical management recommendations for prisoners with swallowing difficulties
Wider context from the report “Prisoners accommodated in the Older Prisoners Unit of HM Prison Norwich do not have appropriate access to speech and language therapists who can provide assessments to those with swallowing difficulties and make necessary recommendations as to their medical management including the regulation of fluid and food intake and the provision of a soft diet .
” Open source report
Includes reports addressed to a minister or senior office-holder acting for this organisation.
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations