Concerns raised 3 Lack of policy or guidance for additional checks of prisoners with repeated NPS use View source Failure to communicate elevated NPS-related risk to Healthcare and prison officers View source Unavailability of relevant prisoner medical information to drug workers View source
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AI-generated summary
Jerome Jason Omri JONES · 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
Jerome Jason Omri Jones was a serving prisoner who died in hospital after being found unresponsive in his cell, following suspected use of a synthetic cannabinoid and in the context of a congenital heart defect. The concerns included the absence of guidance for additional checks after repeated NPS use, no clear method for communicating his increased risk to healthcare or prison officers, and limited access by drug workers to relevant medical information.
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 Shropshire Community Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of policy or guidance for additional checks of prisoners with repeated NPS use
Wider context from the report “(1)During the inquest evidence was heard that apart from some hourly checks by prison officers during the evening of the incident on 20/10/17 (the third known instance of NPS use by the deceased) no other specific checks were made on the deceased leading up to the date of his death . This was a prisoner who had 3 known instances of NPS use within a relatively short space of time. I heard evidence that the requirement for further checks would have had to come from the Healthcare team rather than from prison officers . I was told here is no policy or guidance to cover additional checks for a prisoner in a situation such as this.
” 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 Shropshire Community Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate elevated NPS-related risk to Healthcare and prison officers
Wider context from the report “(2)The inquest heard evidence from two Forward Trust Drug workers who although not medically qualified, considered that Mr Jones was at a ‘higher’ risk from NPS use due to using NPS with his existing congenital heart defect. I was told there was no method of communicating this to either Healthcare or prison officers to enable further periodic checks to be undertaken particularly in light of the recent incident on 20/10/17.
” 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 Shropshire Community Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of relevant prisoner medical information to drug workers
Wider context from the report “(3)The two Forward Trust Drug workers were only aware of Mr Jones existing heart condition because he disclosed this to them himself. This enabled them specifically to tailor their advice to cover the impact of Mr Jones continued NPS use on his heart. Forward Trust do not appear to have access to prisoner medical records for reasons of patient confidentiality and there does not appear to be any alternative way of ensuring they have all the information about a prisoner in order to help them with their drug use .
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Forward Trust's access to medical records is being addressed with NHS England, the service commissioner.
Verbatim wording from the response “Healthcare staff were aware of his condition. The Forward Trust can be given access to medical records, they are in discussion with NHS England, the commissioner of the service, to action this. As with any other prisoner arriving at HMP/YOI Stoke Heath, Mr Jones would have been asked at reception as part of disability information sharing if he had any conditions that he would like to share with the prison authorities. This form would have been sent to the disability liaison officer at the prison. As with any other Trust patient we would not share medical information without the patient or patient representative consent.” Source location 2018-0369-Response-by-Shropshire-Community-Health-NHS-Trust
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Medical information will not be shared without the patient's or representative's consent.
Verbatim wording from the response “Healthcare staff were aware of his condition. The Forward Trust can be given access to medical records, they are in discussion with NHS England, the commissioner of the service, to action this. As with any other prisoner arriving at HMP/YOI Stoke Heath, Mr Jones would have been asked at reception as part of disability information sharing if he had any conditions that he would like to share with the prison authorities. This form would have been sent to the disability liaison officer at the prison. As with any other Trust patient we would not share medical information without the patient or patient representative consent.” Source location 2018-0369-Response-by-Shropshire-Community-Health-NHS-Trust
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations