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.
×
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 Sodexo; 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 Sodexo; 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 Sodexo; 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 Sodexo; 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 Sodexo; 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 Sodexo; 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 Sodexo; 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 Sodexo; 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 Sodexo; 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 Sodexo; 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 Sodexo; 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 Sodexo; 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 Sodexo; 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 Sodexo; 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
×
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 Ringfence key safety tasks and safer-custody staff against future resourcing pressures.
Verbatim wording from the response “We know that you will share a copy of this response with the families, and we would like to again express our sincere condolences for their loss. Following the inquests Sodexo have ringfenced key safety tasks and safer custody staff in the event of changes in resourcing pressures. The implementation of learning from these sad deaths is a priority.” Source location Response from Sodexo
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 Remind staff across Sodexo prisons to record concerns in NOMIS and wing observation books.
Verbatim wording from the response “○ Senior Staff morning meeting, including the Prison Director and Head of Healthcare. Within this meeting, prison staff present information about prisoners of concern following incidents or receiving of intelligence reports.
○ Weekly Safety Intervention Meeting (SIM). Attendance includes physical healthcare, mental health staff and psychology
○ Monthly Safer Custody Meeting
○ Complex case meetings, ad hoc, focusing on prisoners of concern
○ ACCT reviews
○ Briefings on each prison wing at each shift change. Staff concerns (prison or healthcare staff) are recorded in Wing Observation Book. Staff at all Sodexo prisons have been reminded of the importance of recording concerns in NOMIS and the wing observation book.” Source location Response from Sodexo
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 Introduce and operate a digital Reception Screening Risk Assessment tool across Sodexo prisons to identify arrival risks and generate alerts for staff review.
Verbatim wording from the response “- Sodexo have recently introduced a digital Reception Screening Risk Assessment (RSRA) tool across its prisons, implemented on CMS following 2 years of development and trialling led by Sodexo in partnership with Unilink” Source location Response from Sodexo
Open published response
×
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 Overlapping organisations, separate officer statuses, and late Ministry disclosure made admissions without trespassing on inquest evidence difficult.
Verbatim wording from the response “Whilst Sodexo always considers early admissions and agreed facts, the unique circumstances of these cases, with the number of overlapping organisations involved and individual officers with separate IP status, as well as ongoing and late disclosure of relevant material by the Ministry of Justice, meant that admissions by Sodexo, without trespassing on factual evidence due to be heard at the inquest involving other IPs, was more difficult and complex than would usually be the case. There are three further inquests involving Sodexo concerning deaths at HMP Lowdham Grange, and Sodexo will give careful consideration to admissions and agreement of facts in relation to each.” Source location Response from Sodexo
Open published response
17 Jan 2024 Kane Christopher Boyce · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 10 Failure to implement learning from investigations following deaths in custody View source Unclear and potentially inaccurate Early Learning Review investigation methodology View source Failure to control the deliberate ignoring of prisoner cell bells View source Lack of policy governing the isolation of power to cells View source Failure to follow the Under the Influence Policy View source Poor quality Early Learning Review failing to identify safety issues and learning View source Lack of understanding and training on key dates or anniversaries as self-harm risk factors View source Failure to recognise the ACCT threshold without a verbalised self-harm statement View source Failure to make agreed factual admissions of shortcomings during death in custody inquests View source Lack of a culture of candour and staff reflection after deaths in custody View source See 7 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Kane Christopher Boyce · 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
Kane Christopher Boyce, a serving prisoner at HMP Lowdham Grange, was found with a ligature around his neck on 3 October 2021 and could not be resuscitated. The jury found that alcohol intoxication and the failure of staff to share information, open an under-the-influence log, adequately monitor him, and consider risk when isolating cell power and ignoring cell bells contributed to his death. The report raised concerns about these practices, staff understanding of relevant policies, learning from deaths in custody, and organisational candour.
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 Sodexo; that does not assign responsibility.
PFD Monitor interpretation Failure to implement learning from investigations following deaths in custody
Wider context from the report “5. A failure to implement learning from the investigations that follow deaths in custody
Many of the staff giving evidence explained that they had not read the PPO report, nor were they aware of the issues identified by the PPO prior to giving evidence at the inquest. I have seen no evidence of the systems in place at HMP Lowdham Grange to seek to learn from deaths in custody at the earliest opportunity .
” 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 Sodexo; that does not assign responsibility.
PFD Monitor interpretation Unclear and potentially inaccurate Early Learning Review investigation methodology
Wider context from the report “6. Poor Quality Early Learning Review process, November 2021
While it is recognised that the ELR process is designed to capture information at a very early stage of the investigation, it is nevertheless an important tool in seeking to identify safety issues that should be addressed swiftly in order to prevent future deaths.
The central issue in this case was obvious from the outset, as recorded in various intelligence reports submitted by staff on the night of the death, namely, a number of members of staff suspected Kane to be under the influence of alcohol yet failed to take the necessary steps to seek to safeguard against harm.
On page 4 of the ELR it is concluded that “all procedures were followed” and there were no local or national recommendations for learning lessons. It is difficult to rationalise this conclusion against the evidence available even at the earliest stages of the investigation. The author was clearly aware that staff had considered Kane to be under the influence of alcohol (see page 1) and should have been aware that no Under the Influence Log existed. The author simply notes that “the policy has been reviewed”. There is no explanation as to why the policy wasn’t followed. Was the policy unclear in its requirements? Was there an absence of staff training on the policy? Of great concern to me is the fact that staff giving evidence at the inquest still seemed to fail to grasp the significance of intoxication as a risk factor for self harm.
My concerns extend beyond the quality of the report, but also to the accuracy of the same.
The report is written in such a way as to create the impression that the author interviewed key members of staff. Comments are attributed to staff in particular points in time, yet all prison staff witnesses denied ever having been interviewed as part of the ELR process . It is unclear exactly what methodology the author has used during the investigation . I am concerned that the quality of the investigation has led to missed opportunities to have identified these issues at the outset .
” 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 Sodexo; that does not assign responsibility.
PFD Monitor interpretation Failure to control the deliberate ignoring of prisoner cell bells
Wider context from the report “1. Ignoring Cell Bells
I heard evidence that staff were engaging in the deliberate ignoring of prisoner cell bells . I have seen no local policy which either prohibits such activity, or, if such activity is permitted, supports staff to make risk-based considerations about how and when to ignore cell bells .
I observe that deliberately ignoring cell bells appears to be a wholly dangerous practice as the cell bell is the only method of communication between prisoner and staff during periods of lock up, including night state. The practice appears to be all the more dangerous when one considers some staff suspected Kane to be in a state of heightened emotion and acting under the influence of alcohol.
” 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 Sodexo; that does not assign responsibility.
PFD Monitor interpretation Lack of policy governing the isolation of power to cells
Wider context from the report “2. Isolating power to cells
As above, I have seen no policy which supports the isolation of power to cells including who has the power to make such a decision, how long the power should be isolated for, and whether staff are required to consider any risk factors when determining whether to isolate power 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 Sodexo; that does not assign responsibility.
PFD Monitor interpretation Failure to follow the Under the Influence Policy
Wider context from the report “3. Failure to follow the local Under the Influence Policy
Three members of staff suspected Kane was under the influence of something in the hours before his death, yet none opened an under the influence log or sought any medical advice about how frequently to check on him, what signs of deterioration to look out for, and when to seek further assistance .
” 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 Sodexo; that does not assign responsibility.
PFD Monitor interpretation Poor quality Early Learning Review failing to identify safety issues and learning
Wider context from the report “6. Poor Quality Early Learning Review process, November 2021
While it is recognised that the ELR process is designed to capture information at a very early stage of the investigation, it is nevertheless an important tool in seeking to identify safety issues that should be addressed swiftly in order to prevent future deaths.
The central issue in this case was obvious from the outset, as recorded in various intelligence reports submitted by staff on the night of the death, namely, a number of members of staff suspected Kane to be under the influence of alcohol yet failed to take the necessary steps to seek to safeguard against harm.
On page 4 of the ELR it is concluded that “all procedures were followed” and there were no local or national recommendations for learning lessons . It is difficult to rationalise this conclusion against the evidence available even at the earliest stages of the investigation. The author was clearly aware that staff had considered Kane to be under the influence of alcohol (see page 1) and should have been aware that no Under the Influence Log existed. The author simply notes that “the policy has been reviewed”. There is no explanation as to why the policy wasn’t followed . Was the policy unclear in its requirements? Was there an absence of staff training on the policy? Of great concern to me is the fact that staff giving evidence at the inquest still seemed to fail to grasp the significance of intoxication as a risk factor for self harm.
My concerns extend beyond the quality of the report, but also to the accuracy of the same.
The report is written in such a way as to create the impression that the author interviewed key members of staff. Comments are attributed to staff in particular points in time, yet all prison staff witnesses denied ever having been interviewed as part of the ELR process. It is unclear exactly what methodology the author has used during the investigation. I am concerned that the quality of the investigation has led to missed opportunities to have identified these issues at the outset.
” 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 Sodexo; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding and training on key dates or anniversaries as self-harm risk factors
Wider context from the report “4. Lack of understanding of Prison Service Instruction 64/2011, and possible discord between local policy and the PSI
A number of prison officers believed Kane’s birthday was incapable of amounting to a “key date or anniversary” for the purposes of PSI 64/2011 . It seems to me to common sense that a birthday, being the anniversary of one’s birth, could amount to a potential trigger date for heightened emotions when considering a prisoner’s risk of self harm and suicide. That is not to say it would be so for each and every prisoner, but perhaps something to be cognisant of when dealing with an emotional and intoxicated prisoner. I have seen no evidence that this is covered in Sodexo’s training for staff on the ACCT process , if indeed any series of training exists.
A number of prison officers gave evidence that an ACCT was not necessary because Kane had not said to anyone that he was going to harm himself (either fatally or otherwise). Serco’s Safer Prison Operating Policy (August 2022) is confusing on this point and seems to suggest at paragraph 3.4 that staff should only open an ACCT when a statement of self-harm has been verbalised. This is not consistent with the PSI. Sodexo have not offered for scrutiny any local policy, guidance or training material on the threshold for opening an ACCT, but even if such exists, it appears some staff continue to labour under the misapprehension that a prisoner must say they are thinking of harming themselves before an ACCT can be opened.
” 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 Sodexo; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise the ACCT threshold without a verbalised self-harm statement
Wider context from the report “4. Lack of understanding of Prison Service Instruction 64/2011, and possible discord between local policy and the PSI
A number of prison officers believed Kane’s birthday was incapable of amounting to a “key date or anniversary” for the purposes of PSI 64/2011. It seems to me to common sense that a birthday, being the anniversary of one’s birth, could amount to a potential trigger date for heightened emotions when considering a prisoner’s risk of self harm and suicide. That is not to say it would be so for each and every prisoner, but perhaps something to be cognisant of when dealing with an emotional and intoxicated prisoner. I have seen no evidence that this is covered in Sodexo’s training for staff on the ACCT process, if indeed any series of training exists.
A number of prison officers gave evidence that an ACCT was not necessary because Kane had not said to anyone that he was going to harm himself (either fatally or otherwise). Serco’s Safer Prison Operating Policy (August 2022) is confusing on this point and seems to suggest at paragraph 3.4 that staff should only open an ACCT when a statement of self-harm has been verbalised. This is not consistent with the PSI. Sodexo have not offered for scrutiny any local policy, guidance or training material on the threshold for opening an ACCT, but even if such exists, it appears some staff continue to labour under the misapprehension that a prisoner must say they are thinking of harming themselves before an ACCT can be opened .
” 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 Sodexo; that does not assign responsibility.
PFD Monitor interpretation Failure to make agreed factual admissions of shortcomings during death in custody inquests
Wider context from the report “7. A Lack of Candour – both organisationally and individually
I would be very interested to understand how the duty of candour applies to the prison service and those individuals within the employ of the service (whether employed directly or through a private provider, as in this case).
There is a statutory duty of candour applicable to healthcare organisations and professionals, as well as a more recent agreement by the College of Policing for members to adhere to a Code of Candour.
In practise, candour creates a culture of being open and honest with all stakeholders by accepting when things go wrong, taking remedial steps as soon as practicable, and thus reducing the risk of events repeating themselves. In the context of a death, candour from the outset is essential in order to support the bereaved family.
The position adopted by Serco in this inquest, as it has in other inquests, could be said to represent the very opposite of candour. Having heard evidence supplied on oath by their own staff members that there were multiple failures to open an under the influence log (evidence which was not contested) the organisation nevertheless required the Jury to return a finding on this issue, and each and every issue, instead of a factual finding being presented to the jury as agreed by all Interested Persons .
The inquest is not an adversarial process, there is no burden of proof. The Interested Persons are under a duty to assist the investigative process in an open and honest manner. By identifying those issues that genuinely require determination by the jury, and those on which there is agreement. Sadly, in my extensive experience of conducting Article 2 inquests locally, this is not an isolated example of the uncomfortable position adopted by the prison service in failing to put forward sensible and reasonable factual admissions of shortcomings.
I am concerned by the apparent absence of a culture of candour supporting those staff who work within the prison service. Many of the staff members giving evidence explained that the inquest was the first time it had been suggested to them that they had not adhered to policy. In the intervening period of over two years between Kane’s death and the inquest, no-one at the prison had asked key staff to reflect on the care they provided to Kane that night and consider areas of learning. Again, this is not a position unique to this inquest, and is of great concern in the context of a rising number of self-inflicted prisoner deaths at HMP Lowdham Grange since Kane’s tragic death in 2021.
I would be grateful if your response could address what steps have been, or are being taken, to ensure that candour is applied throughout the death in custody process.
” 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 Sodexo; that does not assign responsibility.
PFD Monitor interpretation Lack of a culture of candour and staff reflection after deaths in custody
Wider context from the report “7. A Lack of Candour – both organisationally and individually
I would be very interested to understand how the duty of candour applies to the prison service and those individuals within the employ of the service (whether employed directly or through a private provider, as in this case).
There is a statutory duty of candour applicable to healthcare organisations and professionals, as well as a more recent agreement by the College of Policing for members to adhere to a Code of Candour.
In practise, candour creates a culture of being open and honest with all stakeholders by accepting when things go wrong, taking remedial steps as soon as practicable, and thus reducing the risk of events repeating themselves. In the context of a death, candour from the outset is essential in order to support the bereaved family.
The position adopted by Serco in this inquest, as it has in other inquests, could be said to represent the very opposite of candour. Having heard evidence supplied on oath by their own staff members that there were multiple failures to open an under the influence log (evidence which was not contested) the organisation nevertheless required the Jury to return a finding on this issue, and each and every issue, instead of a factual finding being presented to the jury as agreed by all Interested Persons.
The inquest is not an adversarial process, there is no burden of proof. The Interested Persons are under a duty to assist the investigative process in an open and honest manner. By identifying those issues that genuinely require determination by the jury, and those on which there is agreement. Sadly, in my extensive experience of conducting Article 2 inquests locally, this is not an isolated example of the uncomfortable position adopted by the prison service in failing to put forward sensible and reasonable factual admissions of shortcomings.
I am concerned by the apparent absence of a culture of candour supporting those staff who work within the prison service . Many of the staff members giving evidence explained that the inquest was the first time it had been suggested to them that they had not adhered to policy. In the intervening period of over two years between Kane’s death and the inquest, no-one at the prison had asked key staff to reflect on the care they provided to Kane that night and consider areas of learning . Again, this is not a position unique to this inquest, and is of great concern in the context of a rising number of self-inflicted prisoner deaths at HMP Lowdham Grange since Kane’s tragic death in 2021.
I would be grateful if your response could address what steps have been, or are being taken, to ensure that candour is applied throughout the death in custody process.
” 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 Change senior managers and officers as part of ongoing efforts to address failures in observations and compliance with the Under the Influence Policy.
Verbatim wording from the response “Sodexo have concerns about the practices of the staff that transferred to Sodexo with HMP Lowdham Grange. These include failures of staff to conduct observations and follow the Under the Influence Policy. This is part of an ongoing culture change that we are trying to address but one that takes time and has to date involved changes to Senior Managers and Officers at the prison.” Source location Response from Sodexo
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 Deliver the national ACCT, ACCT Assessor and Case Coordinator training packages using nationally trained Sodexo facilitators and HMPPS facilitators.
Verbatim wording from the response “Sodexo follow the national Prison Service Instruction 64/2011 which provides the framework underpinning any local policy. Sodexo deliver to staff the national training package issued by HMPPS for ACCT, version 6 and ACCT Assessor. To enable this Sodexo facilitators complete the national ACCT Train the Trainer course delivered by HMPPS facilitators. Relevant Sodexo staff also receive the national training package delivered directly by HMPPS facilitators on ACCT Case Coordinators.” Source location Response from Sodexo
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 Require Early Learning Reviews after deaths in custody and ensure resulting recommendations and learning are investigated and implemented.
Verbatim wording from the response “Following a death in custody at a Sodexo prison (whilst under Sodexo operational management) an Early Learning Review is required – this should be completed within 7 days. The Early Learning Review notes areas of good practice and recommendations, the Director is expected to ensure that any recommendations are complied with – alongside any recommendations made by the PPO.” Source location Response from Sodexo
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 Produce a policy prohibiting deliberate cell-bell ignoring and requiring bells to be answered within five minutes.
Verbatim wording from the response “Sodexo agrees that wilfully ignoring cell bells is a wholly dangerous practice and one that is not permitted by Sodexo in any circumstances. Sodexo requires all cell bells at HMP Lowdham Grange to be answered within 5 minutes.” Source location Response from Sodexo
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 Provide ACCT refresher training to all staff when operational management returns to Sodexo, unless they have completed it earlier.
Verbatim wording from the response “When the operational management of the prison returns to Sodexo all staff will undergo ACCT refresher training, if not done before.” Source location Response from Sodexo
Open published response
×
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 Sodexo’s death-in-custody learning processes apply only while the prison is under Sodexo’s operational management.
Verbatim wording from the response “The above processes only apply when the prison is under Sodexo’s operational management.” Source location Response from Sodexo
Open published response
10 Jan 2019 Natasha Learline CHIN · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 12 Lack of audit of opiate and alcohol withdrawal observations View source Inadequate training on opiate and alcohol withdrawal signs and dangers View source Failure to make datix referrals for missed medications View source Unclear governance for non-administration of prescribed medication View source Unclear and incomplete protocols for opiate and alcohol withdrawal View source Lack of audit of on-time administration of critical medication View source Lack of verification that medication safety matters have been adequately addressed View source Inadequate training of clinical staff in completing withdrawal scales View source Lack of audit of nurse prescribing and pre-prescription record checks View source Lack of audit of medical-record accuracy on System 1 View source Lack of follow-up and recording of prescribed medication non-attendance View source Lack of medication information sharing with discipline staff View source See 9 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Natasha Learline CHIN · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Natasha Learline Chin died in her cell at HMP Bronzefield on 19 July 2016 after profuse vomiting associated with undertreated opiate and alcohol withdrawal. The report identified concerns about delayed medication, inadequate monitoring and escalation, failures in record-keeping and governance, and insufficient auditing and training.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sodexo; that does not assign responsibility.
PFD Monitor interpretation Lack of audit of opiate and alcohol withdrawal observations
Wider context from the report “1. The prison officer with responsibility for the wing on which Miss Chin was resident was not privy to what medication she was prescribed nor when it should be administered. There is no system in place for consent to be obtained from prisoners for this information to be shared with discipline staff.
2. The Sodexo Justice Service Protocols in respect of opiate and alcohol withdrawal did not adequately mirror the National Protocols and were, in parts, unclear and difficult to comprehend.
3. Nurses failed to make any datix referrals in respect of missed medications.
4. The following matters have to date not been formally audited by Sodexo Justice Services:
i.) Whether prisoners who do not attend for prescribed medications are followed up and the reason for non-attendance is properly recorded.
ii.) Whether critical medication is administered on time.
iii.) Whether proper observations are undertaken in line with national or local protocols in respect of opiate and alcohol withdrawal.
iv.) Whether medical records on System 1 are accurately recorded.
v.) Whether the Patient Guidance Directions in respect of prescribing by nurses are adhered to, and whether medical records are checked before any prescriptions are made by nurses pursuant to the directive.
5. As a consequence it is not possible for Sodexo Justice Services to know whether the matters raised in 4.(i) to (v) have been adequately addressed.
6. The response by Sodexo Justice Services to the issues identified in the report dated the 13th April 2016 of Her Majesty’s Chief Inspector of Prisons in respect of non-administration of prescribed medication was inadequate. It does not appear that there was a clear line of governance in respect of this matter.
7. Whether there is adequate training:
i.) of discipline and clinical staff, including agency staff, to make them aware of the signs and dangers of opiate and alcohol withdrawal.
ii.) of clinical staff in respect of the completion of opiate and alcohol withdrawal scales.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sodexo; that does not assign responsibility.
PFD Monitor interpretation Inadequate training on opiate and alcohol withdrawal signs and dangers
Wider context from the report “1. The prison officer with responsibility for the wing on which Miss Chin was resident was not privy to what medication she was prescribed nor when it should be administered. There is no system in place for consent to be obtained from prisoners for this information to be shared with discipline staff.
2. The Sodexo Justice Service Protocols in respect of opiate and alcohol withdrawal did not adequately mirror the National Protocols and were, in parts, unclear and difficult to comprehend.
3. Nurses failed to make any datix referrals in respect of missed medications.
4. The following matters have to date not been formally audited by Sodexo Justice Services:
i.) Whether prisoners who do not attend for prescribed medications are followed up and the reason for non-attendance is properly recorded.
ii.) Whether critical medication is administered on time.
iii.) Whether proper observations are undertaken in line with national or local protocols in respect of opiate and alcohol withdrawal.
iv.) Whether medical records on System 1 are accurately recorded.
v.) Whether the Patient Guidance Directions in respect of prescribing by nurses are adhered to, and whether medical records are checked before any prescriptions are made by nurses pursuant to the directive.
5. As a consequence it is not possible for Sodexo Justice Services to know whether the matters raised in 4.(i) to (v) have been adequately addressed.
6. The response by Sodexo Justice Services to the issues identified in the report dated the 13th April 2016 of Her Majesty’s Chief Inspector of Prisons in respect of non-administration of prescribed medication was inadequate. It does not appear that there was a clear line of governance in respect of this matter.
7. Whether there is adequate training:
i.) of discipline and clinical staff, including agency staff, to make them aware of the signs and dangers of opiate and alcohol withdrawal.
ii.) of clinical staff in respect of the completion of opiate and alcohol withdrawal scales.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sodexo; that does not assign responsibility.
PFD Monitor interpretation Failure to make datix referrals for missed medications
Wider context from the report “1. The prison officer with responsibility for the wing on which Miss Chin was resident was not privy to what medication she was prescribed nor when it should be administered. There is no system in place for consent to be obtained from prisoners for this information to be shared with discipline staff.
2. The Sodexo Justice Service Protocols in respect of opiate and alcohol withdrawal did not adequately mirror the National Protocols and were, in parts, unclear and difficult to comprehend.
3. Nurses failed to make any datix referrals in respect of missed medications.
4. The following matters have to date not been formally audited by Sodexo Justice Services:
i.) Whether prisoners who do not attend for prescribed medications are followed up and the reason for non-attendance is properly recorded.
ii.) Whether critical medication is administered on time.
iii.) Whether proper observations are undertaken in line with national or local protocols in respect of opiate and alcohol withdrawal.
iv.) Whether medical records on System 1 are accurately recorded.
v.) Whether the Patient Guidance Directions in respect of prescribing by nurses are adhered to, and whether medical records are checked before any prescriptions are made by nurses pursuant to the directive.
5. As a consequence it is not possible for Sodexo Justice Services to know whether the matters raised in 4.(i) to (v) have been adequately addressed.
6. The response by Sodexo Justice Services to the issues identified in the report dated the 13th April 2016 of Her Majesty’s Chief Inspector of Prisons in respect of non-administration of prescribed medication was inadequate. It does not appear that there was a clear line of governance in respect of this matter.
7. Whether there is adequate training:
i.) of discipline and clinical staff, including agency staff, to make them aware of the signs and dangers of opiate and alcohol withdrawal.
ii.) of clinical staff in respect of the completion of opiate and alcohol withdrawal scales.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sodexo; that does not assign responsibility.
PFD Monitor interpretation Unclear governance for non-administration of prescribed medication
Wider context from the report “1. The prison officer with responsibility for the wing on which Miss Chin was resident was not privy to what medication she was prescribed nor when it should be administered. There is no system in place for consent to be obtained from prisoners for this information to be shared with discipline staff.
2. The Sodexo Justice Service Protocols in respect of opiate and alcohol withdrawal did not adequately mirror the National Protocols and were, in parts, unclear and difficult to comprehend.
3. Nurses failed to make any datix referrals in respect of missed medications.
4. The following matters have to date not been formally audited by Sodexo Justice Services:
i.) Whether prisoners who do not attend for prescribed medications are followed up and the reason for non-attendance is properly recorded.
ii.) Whether critical medication is administered on time.
iii.) Whether proper observations are undertaken in line with national or local protocols in respect of opiate and alcohol withdrawal.
iv.) Whether medical records on System 1 are accurately recorded.
v.) Whether the Patient Guidance Directions in respect of prescribing by nurses are adhered to, and whether medical records are checked before any prescriptions are made by nurses pursuant to the directive.
5. As a consequence it is not possible for Sodexo Justice Services to know whether the matters raised in 4.(i) to (v) have been adequately addressed.
6. The response by Sodexo Justice Services to the issues identified in the report dated the 13th April 2016 of Her Majesty’s Chief Inspector of Prisons in respect of non-administration of prescribed medication was inadequate. It does not appear that there was a clear line of governance in respect of this matter.
7. Whether there is adequate training:
i.) of discipline and clinical staff, including agency staff, to make them aware of the signs and dangers of opiate and alcohol withdrawal.
ii.) of clinical staff in respect of the completion of opiate and alcohol withdrawal scales.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sodexo; that does not assign responsibility.
PFD Monitor interpretation Unclear and incomplete protocols for opiate and alcohol withdrawal
Wider context from the report “1. The prison officer with responsibility for the wing on which Miss Chin was resident was not privy to what medication she was prescribed nor when it should be administered. There is no system in place for consent to be obtained from prisoners for this information to be shared with discipline staff.
2. The Sodexo Justice Service Protocols in respect of opiate and alcohol withdrawal did not adequately mirror the National Protocols and were, in parts, unclear and difficult to comprehend.
3. Nurses failed to make any datix referrals in respect of missed medications.
4. The following matters have to date not been formally audited by Sodexo Justice Services:
i.) Whether prisoners who do not attend for prescribed medications are followed up and the reason for non-attendance is properly recorded.
ii.) Whether critical medication is administered on time.
iii.) Whether proper observations are undertaken in line with national or local protocols in respect of opiate and alcohol withdrawal.
iv.) Whether medical records on System 1 are accurately recorded.
v.) Whether the Patient Guidance Directions in respect of prescribing by nurses are adhered to, and whether medical records are checked before any prescriptions are made by nurses pursuant to the directive.
5. As a consequence it is not possible for Sodexo Justice Services to know whether the matters raised in 4.(i) to (v) have been adequately addressed.
6. The response by Sodexo Justice Services to the issues identified in the report dated the 13th April 2016 of Her Majesty’s Chief Inspector of Prisons in respect of non-administration of prescribed medication was inadequate. It does not appear that there was a clear line of governance in respect of this matter.
7. Whether there is adequate training:
i.) of discipline and clinical staff, including agency staff, to make them aware of the signs and dangers of opiate and alcohol withdrawal.
ii.) of clinical staff in respect of the completion of opiate and alcohol withdrawal scales.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sodexo; that does not assign responsibility.
PFD Monitor interpretation Lack of audit of on-time administration of critical medication
Wider context from the report “1. The prison officer with responsibility for the wing on which Miss Chin was resident was not privy to what medication she was prescribed nor when it should be administered. There is no system in place for consent to be obtained from prisoners for this information to be shared with discipline staff.
2. The Sodexo Justice Service Protocols in respect of opiate and alcohol withdrawal did not adequately mirror the National Protocols and were, in parts, unclear and difficult to comprehend.
3. Nurses failed to make any datix referrals in respect of missed medications.
4. The following matters have to date not been formally audited by Sodexo Justice Services:
i.) Whether prisoners who do not attend for prescribed medications are followed up and the reason for non-attendance is properly recorded.
ii.) Whether critical medication is administered on time.
iii.) Whether proper observations are undertaken in line with national or local protocols in respect of opiate and alcohol withdrawal.
iv.) Whether medical records on System 1 are accurately recorded.
v.) Whether the Patient Guidance Directions in respect of prescribing by nurses are adhered to, and whether medical records are checked before any prescriptions are made by nurses pursuant to the directive.
5. As a consequence it is not possible for Sodexo Justice Services to know whether the matters raised in 4.(i) to (v) have been adequately addressed.
6. The response by Sodexo Justice Services to the issues identified in the report dated the 13th April 2016 of Her Majesty’s Chief Inspector of Prisons in respect of non-administration of prescribed medication was inadequate. It does not appear that there was a clear line of governance in respect of this matter.
7. Whether there is adequate training:
i.) of discipline and clinical staff, including agency staff, to make them aware of the signs and dangers of opiate and alcohol withdrawal.
ii.) of clinical staff in respect of the completion of opiate and alcohol withdrawal scales.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sodexo; that does not assign responsibility.
PFD Monitor interpretation Lack of verification that medication safety matters have been adequately addressed
Wider context from the report “1. The prison officer with responsibility for the wing on which Miss Chin was resident was not privy to what medication she was prescribed nor when it should be administered. There is no system in place for consent to be obtained from prisoners for this information to be shared with discipline staff.
2. The Sodexo Justice Service Protocols in respect of opiate and alcohol withdrawal did not adequately mirror the National Protocols and were, in parts, unclear and difficult to comprehend.
3. Nurses failed to make any datix referrals in respect of missed medications.
4. The following matters have to date not been formally audited by Sodexo Justice Services:
i.) Whether prisoners who do not attend for prescribed medications are followed up and the reason for non-attendance is properly recorded.
ii.) Whether critical medication is administered on time.
iii.) Whether proper observations are undertaken in line with national or local protocols in respect of opiate and alcohol withdrawal.
iv.) Whether medical records on System 1 are accurately recorded.
v.) Whether the Patient Guidance Directions in respect of prescribing by nurses are adhered to, and whether medical records are checked before any prescriptions are made by nurses pursuant to the directive.
5. As a consequence it is not possible for Sodexo Justice Services to know whether the matters raised in 4.(i) to (v) have been adequately addressed.
6. The response by Sodexo Justice Services to the issues identified in the report dated the 13th April 2016 of Her Majesty’s Chief Inspector of Prisons in respect of non-administration of prescribed medication was inadequate. It does not appear that there was a clear line of governance in respect of this matter.
7. Whether there is adequate training:
i.) of discipline and clinical staff, including agency staff, to make them aware of the signs and dangers of opiate and alcohol withdrawal.
ii.) of clinical staff in respect of the completion of opiate and alcohol withdrawal scales.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sodexo; that does not assign responsibility.
PFD Monitor interpretation Inadequate training of clinical staff in completing withdrawal scales
Wider context from the report “1. The prison officer with responsibility for the wing on which Miss Chin was resident was not privy to what medication she was prescribed nor when it should be administered. There is no system in place for consent to be obtained from prisoners for this information to be shared with discipline staff.
2. The Sodexo Justice Service Protocols in respect of opiate and alcohol withdrawal did not adequately mirror the National Protocols and were, in parts, unclear and difficult to comprehend.
3. Nurses failed to make any datix referrals in respect of missed medications.
4. The following matters have to date not been formally audited by Sodexo Justice Services:
i.) Whether prisoners who do not attend for prescribed medications are followed up and the reason for non-attendance is properly recorded.
ii.) Whether critical medication is administered on time.
iii.) Whether proper observations are undertaken in line with national or local protocols in respect of opiate and alcohol withdrawal.
iv.) Whether medical records on System 1 are accurately recorded.
v.) Whether the Patient Guidance Directions in respect of prescribing by nurses are adhered to, and whether medical records are checked before any prescriptions are made by nurses pursuant to the directive.
5. As a consequence it is not possible for Sodexo Justice Services to know whether the matters raised in 4.(i) to (v) have been adequately addressed.
6. The response by Sodexo Justice Services to the issues identified in the report dated the 13th April 2016 of Her Majesty’s Chief Inspector of Prisons in respect of non-administration of prescribed medication was inadequate. It does not appear that there was a clear line of governance in respect of this matter.
7. Whether there is adequate training:
i.) of discipline and clinical staff, including agency staff, to make them aware of the signs and dangers of opiate and alcohol withdrawal.
ii.) of clinical staff in respect of the completion of opiate and alcohol withdrawal scales.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sodexo; that does not assign responsibility.
PFD Monitor interpretation Lack of audit of nurse prescribing and pre-prescription record checks
Wider context from the report “1. The prison officer with responsibility for the wing on which Miss Chin was resident was not privy to what medication she was prescribed nor when it should be administered. There is no system in place for consent to be obtained from prisoners for this information to be shared with discipline staff.
2. The Sodexo Justice Service Protocols in respect of opiate and alcohol withdrawal did not adequately mirror the National Protocols and were, in parts, unclear and difficult to comprehend.
3. Nurses failed to make any datix referrals in respect of missed medications.
4. The following matters have to date not been formally audited by Sodexo Justice Services:
i.) Whether prisoners who do not attend for prescribed medications are followed up and the reason for non-attendance is properly recorded.
ii.) Whether critical medication is administered on time.
iii.) Whether proper observations are undertaken in line with national or local protocols in respect of opiate and alcohol withdrawal.
iv.) Whether medical records on System 1 are accurately recorded.
v.) Whether the Patient Guidance Directions in respect of prescribing by nurses are adhered to, and whether medical records are checked before any prescriptions are made by nurses pursuant to the directive.
5. As a consequence it is not possible for Sodexo Justice Services to know whether the matters raised in 4.(i) to (v) have been adequately addressed.
6. The response by Sodexo Justice Services to the issues identified in the report dated the 13th April 2016 of Her Majesty’s Chief Inspector of Prisons in respect of non-administration of prescribed medication was inadequate. It does not appear that there was a clear line of governance in respect of this matter.
7. Whether there is adequate training:
i.) of discipline and clinical staff, including agency staff, to make them aware of the signs and dangers of opiate and alcohol withdrawal.
ii.) of clinical staff in respect of the completion of opiate and alcohol withdrawal scales.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sodexo; that does not assign responsibility.
PFD Monitor interpretation Lack of audit of medical-record accuracy on System 1
Wider context from the report “1. The prison officer with responsibility for the wing on which Miss Chin was resident was not privy to what medication she was prescribed nor when it should be administered. There is no system in place for consent to be obtained from prisoners for this information to be shared with discipline staff.
2. The Sodexo Justice Service Protocols in respect of opiate and alcohol withdrawal did not adequately mirror the National Protocols and were, in parts, unclear and difficult to comprehend.
3. Nurses failed to make any datix referrals in respect of missed medications.
4. The following matters have to date not been formally audited by Sodexo Justice Services:
i.) Whether prisoners who do not attend for prescribed medications are followed up and the reason for non-attendance is properly recorded.
ii.) Whether critical medication is administered on time.
iii.) Whether proper observations are undertaken in line with national or local protocols in respect of opiate and alcohol withdrawal.
iv.) Whether medical records on System 1 are accurately recorded.
v.) Whether the Patient Guidance Directions in respect of prescribing by nurses are adhered to, and whether medical records are checked before any prescriptions are made by nurses pursuant to the directive.
5. As a consequence it is not possible for Sodexo Justice Services to know whether the matters raised in 4.(i) to (v) have been adequately addressed.
6. The response by Sodexo Justice Services to the issues identified in the report dated the 13th April 2016 of Her Majesty’s Chief Inspector of Prisons in respect of non-administration of prescribed medication was inadequate. It does not appear that there was a clear line of governance in respect of this matter.
7. Whether there is adequate training:
i.) of discipline and clinical staff, including agency staff, to make them aware of the signs and dangers of opiate and alcohol withdrawal.
ii.) of clinical staff in respect of the completion of opiate and alcohol withdrawal scales.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sodexo; that does not assign responsibility.
PFD Monitor interpretation Lack of follow-up and recording of prescribed medication non-attendance
Wider context from the report “1. The prison officer with responsibility for the wing on which Miss Chin was resident was not privy to what medication she was prescribed nor when it should be administered. There is no system in place for consent to be obtained from prisoners for this information to be shared with discipline staff.
2. The Sodexo Justice Service Protocols in respect of opiate and alcohol withdrawal did not adequately mirror the National Protocols and were, in parts, unclear and difficult to comprehend.
3. Nurses failed to make any datix referrals in respect of missed medications.
4. The following matters have to date not been formally audited by Sodexo Justice Services:
i.) Whether prisoners who do not attend for prescribed medications are followed up and the reason for non-attendance is properly recorded.
ii.) Whether critical medication is administered on time.
iii.) Whether proper observations are undertaken in line with national or local protocols in respect of opiate and alcohol withdrawal.
iv.) Whether medical records on System 1 are accurately recorded.
v.) Whether the Patient Guidance Directions in respect of prescribing by nurses are adhered to, and whether medical records are checked before any prescriptions are made by nurses pursuant to the directive.
5. As a consequence it is not possible for Sodexo Justice Services to know whether the matters raised in 4.(i) to (v) have been adequately addressed.
6. The response by Sodexo Justice Services to the issues identified in the report dated the 13th April 2016 of Her Majesty’s Chief Inspector of Prisons in respect of non-administration of prescribed medication was inadequate. It does not appear that there was a clear line of governance in respect of this matter.
7. Whether there is adequate training:
i.) of discipline and clinical staff, including agency staff, to make them aware of the signs and dangers of opiate and alcohol withdrawal.
ii.) of clinical staff in respect of the completion of opiate and alcohol withdrawal scales.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sodexo; that does not assign responsibility.
PFD Monitor interpretation Lack of medication information sharing with discipline staff
Wider context from the report “1. The prison officer with responsibility for the wing on which Miss Chin was resident was not privy to what medication she was prescribed nor when it should be administered. There is no system in place for consent to be obtained from prisoners for this information to be shared with discipline staff.
2. The Sodexo Justice Service Protocols in respect of opiate and alcohol withdrawal did not adequately mirror the National Protocols and were, in parts, unclear and difficult to comprehend.
3. Nurses failed to make any datix referrals in respect of missed medications.
4. The following matters have to date not been formally audited by Sodexo Justice Services:
i.) Whether prisoners who do not attend for prescribed medications are followed up and the reason for non-attendance is properly recorded.
ii.) Whether critical medication is administered on time.
iii.) Whether proper observations are undertaken in line with national or local protocols in respect of opiate and alcohol withdrawal.
iv.) Whether medical records on System 1 are accurately recorded.
v.) Whether the Patient Guidance Directions in respect of prescribing by nurses are adhered to, and whether medical records are checked before any prescriptions are made by nurses pursuant to the directive.
5. As a consequence it is not possible for Sodexo Justice Services to know whether the matters raised in 4.(i) to (v) have been adequately addressed.
6. The response by Sodexo Justice Services to the issues identified in the report dated the 13th April 2016 of Her Majesty’s Chief Inspector of Prisons in respect of non-administration of prescribed medication was inadequate. It does not appear that there was a clear line of governance in respect of this matter.
7. Whether there is adequate training:
i.) of discipline and clinical staff, including agency staff, to make them aware of the signs and dangers of opiate and alcohol withdrawal.
ii.) of clinical staff in respect of the completion of opiate and alcohol withdrawal scales.
” Open source report
Concerns raised 7 Failure to comprehensively assess suicide and self-harm risk using documented risk factors and information View source Availability of removable plastic bin liners that can be used for suicide View source Lack of a national pro forma for ACCT opening and decision-making View source Allowing cell door keys to be carried around the neck on tied shoelaces View source Failure of healthcare screening to identify s.136 detentions as an enhanced-risk indicator View source Failure to use trigger-date information to prompt risk reassessment for prisoners outside the ACCT process View source Failure to retrofit cell doors with anti-ligature strips View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Stuart Megginson BAUMBER · 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
Stuart Megginson BAUMBER died by hanging in his cell at HMP Peterborough between 22:30 on 14 November 2013 and 04:10 on 15 November 2013, after being remanded in custody for arson. The jury found that occasions existed when the ACCT process should have been initiated and that inadequate understanding and training contributed to this not happening. The report also raised concerns about ligature points on cell doors, healthcare screening that did not mention section 136 detentions, and items available to prisoners that could facilitate suicide.
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 Sodexo; that does not assign responsibility.
PFD Monitor interpretation Failure to comprehensively assess suicide and self-harm risk using documented risk factors and information
Wider context from the report “8. There appears to be on occasions an over reliance on assessment of current risk as emphasised in the QTLB of 2012 by considering demeanour and presentation at the reception stage. The PPO bulletin of March 2015 highlights deficiencies in this approach. There are known risk factors for suicide and self-harm and active identification of relevant risk factors from documentation and information (e.g. SASH forms and PERs and medical records and an EME report) should be fully considered and balanced against apparent mood so that there is a comprehensive risk assessment.. A pro forma document could record what factors and information have been considered and the reasons for the decision.
” 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 Sodexo; that does not assign responsibility.
PFD Monitor interpretation Availability of removable plastic bin liners that can be used for suicide
Wider context from the report “13. In addition, the deceased referred to experimentation by suffocation in his diary by putting a plastic bag over his head and some cells are known to have plastic removable bin liners which can be used as a means to take 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 Sodexo; that does not assign responsibility.
PFD Monitor interpretation Lack of a national pro forma for ACCT opening and decision-making
Wider context from the report “7. PSI 64/2011 and the Quick Time Learning Bulletin (issue 12 august 2012) which clarified opening an ACCT was the subject of much scrutiny. There seems to be no national pro forma document to guide staff through the process and document the decision making . By contrast, the Act 2 Care risk assessment in the Scottish prison system does provide a structured approach. A pro forma regime would have the advantage of providing an audit trail and can be reviewed for training purposes if shortcomings emerge.
” 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 Sodexo; that does not assign responsibility.
PFD Monitor interpretation Allowing cell door keys to be carried around the neck on tied shoelaces
Wider context from the report “12. Some prisoners at HMP Peterborough are allowed to carry their cell door key which is placed on shoelaces tied together and placed around the neck of the prisoner which clearly creates a self-made ligature for those who may be at risk.
” 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 Sodexo; that does not assign responsibility.
PFD Monitor interpretation Failure of healthcare screening to identify s.136 detentions as an enhanced-risk indicator
Wider context from the report “11. The healthcare screening which is a question and answer discussion based on specifically designed questions is prescriptive. It makes no mention of s.136 detentions which would be a clear indicator of enhanced risk and the deceased had two such detentions.
” 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 Sodexo; that does not assign responsibility.
PFD Monitor interpretation Failure to use trigger-date information to prompt risk reassessment for prisoners outside the ACCT process
Wider context from the report “9. It is known that a prisoners risk of self-harm and/or suicide may increase in certain circumstances. This applied to the deceased in this inquest. HMP Gartree have identified measures to identify potential triggers and there has been developed a database on trigger dates but only for those who are or have been subject to an ACCT . This could be refined to deal with re assessment of risk for many prisoners if key factors exist . (See Equality and Human Rights Commission paper in 2015 on Preventing Deaths in detention of adults with Mental Health Conditions). Again, the PPO bulletin of March 2015 highlighted increased vulnerability where a restraining order was made and this could be input into a database to prompt a review of risk.
” 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 Sodexo; that does not assign responsibility.
PFD Monitor interpretation Failure to retrofit cell doors with anti-ligature strips
Wider context from the report “3. However, whilst the current specification for cell door design now incorporates an anti-ligature strip, there is no retrofit programme in operation and thus, there are significant numbers of cell doors that do not meet the current standard .
” Open source report
25 Feb 2014 Lee Terence Curran · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 6 Failure to fully investigate prisoners’ reported episodes of loss of consciousness View source Failure to conduct NICE-compliant investigations of loss of consciousness View source Failure to make accurate and evidentially grounded entries in prisoners’ medical notes View source Failure to conduct clinical investigations of prisoners experiencing loss of consciousness View source Failure to take full account of family history when clinically investigating prisoners with possible high cholesterol View source Lack of doctors’ awareness of NICE guidelines for transient loss of consciousness 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
Lee Terence Curran · 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 Terence Curran died on 3 May 2011 while in custody at Forest Bank Prison, with naturally occurring ischaemic heart disease identified as the prime cause of death. Before his death, he experienced multiple episodes of transient loss of consciousness that were not diagnosed, and concerns were raised that recommended investigations and follow-up were not provided. Further concerns included incomplete implementation of recommendations, potentially misleading medical-note entries, and inadequate awareness or application of relevant clinical guidelines.
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 Sodexo; that does not assign responsibility.
PFD Monitor interpretation Failure to fully investigate prisoners’ reported episodes of loss of consciousness
Wider context from the report “(3) Evidence given at the Inquest also revealed a need for the training of Doctors working in prisons in that Doctors who provided general practice sessions at the prison (and in the community) gave evidence that they were unaware of the NICE Guidelines for Transient Loss of Consciousness Management in Adults and Young People despite such episodes being common in a prison environment. Additionally evidence was given by a Doctor that efforts were not made to fully investigate Lee Terence Curran’s episodes of loss of consciousness because, the Doctor explained, it was common for prisoners to claim to have suffered losses of consciousness as a form of drug seeking behaviour .
” 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 Sodexo; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct NICE-compliant investigations of loss of consciousness
Wider context from the report “(1) The Prisons and Probation Ombudsman investigated Lee Terence Curran’s death. At the conclusion of that investigation certain recommendations were made, two of which were as follows:
a. “The Head of Healthcare should ensure that healthcare staff take full account of family history when arranging clinical investigations for prisoners who report, or are observed to have possible signs of high cholesterol or hypertension”.
b. “The Head of Healthcare should develop a protocol that is NICE compliant for investigating episodes of loss of consciousness and should ensure that staff conduct clinical investigations of prisoners who experience such episodes.”
Both of these recommendations were accepted. However the evidence given at the Inquest in relation to the implementation of recommendation a. was that all prisoners coming to Forest Bank Prison undertake the reception screening process and any prisoner with any identified, or any sign of, hypertension is referred to the hypertension clinic. A full account of the prisoner’s family history is then taken at that clinic. There was no evidence that any action had been taken to address that part of the Ombudsman’s recommendation that related to prisoners (such as Lee Terence Curran) who reported or showed signs of having high cholesterol.
Likewise with recommendation b. The evidence given at the Inquest with regard to the implementation of that recommendation was that any individual who had a loss of consciousness would be automatically referred to a Doctor. That action does not encompass the whole of the Ombudsman’s recommendation. Particularly it does not ensure that investigations of episodes of loss of consciousness are NICE compliant nor does it ensure that staff conduct clinical investigations of prisoners who experience such episodes. It should be remembered here that Doctors saw Lee Terence Curran on five occasions following episodes of loss of consciousness and the NICE guidelines were not followed at any time .
” 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 Sodexo; that does not assign responsibility.
PFD Monitor interpretation Failure to make accurate and evidentially grounded entries in prisoners’ medical notes
Wider context from the report “(2) Evidence given at the Inquest revealed a potential need for the training of Prison staff as to the manner in which they make entries in prisoners’ medical notes. Expressly, incorrect, and potentially misleading, information had been entered in Lee Terence Curran’s medical notes concerning the episodes of loss of consciousness that he experienced. For example a nurse described one such episode as a “petit mal seizure,” whilst evidence at the Inquest made it clear that such could not have been the case. In addition those attending information did not make the basis upon which they were entering that information clear, that is they entered information that indicated that they had witnessed an event when they had not .
” 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 Sodexo; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct clinical investigations of prisoners experiencing loss of consciousness
Wider context from the report “(1) The Prisons and Probation Ombudsman investigated Lee Terence Curran’s death. At the conclusion of that investigation certain recommendations were made, two of which were as follows:
a. “The Head of Healthcare should ensure that healthcare staff take full account of family history when arranging clinical investigations for prisoners who report, or are observed to have possible signs of high cholesterol or hypertension”.
b. “The Head of Healthcare should develop a protocol that is NICE compliant for investigating episodes of loss of consciousness and should ensure that staff conduct clinical investigations of prisoners who experience such episodes.”
Both of these recommendations were accepted. However the evidence given at the Inquest in relation to the implementation of recommendation a. was that all prisoners coming to Forest Bank Prison undertake the reception screening process and any prisoner with any identified, or any sign of, hypertension is referred to the hypertension clinic. A full account of the prisoner’s family history is then taken at that clinic. There was no evidence that any action had been taken to address that part of the Ombudsman’s recommendation that related to prisoners (such as Lee Terence Curran) who reported or showed signs of having high cholesterol.
Likewise with recommendation b. The evidence given at the Inquest with regard to the implementation of that recommendation was that any individual who had a loss of consciousness would be automatically referred to a Doctor. That action does not encompass the whole of the Ombudsman’s recommendation. Particularly it does not ensure that investigations of episodes of loss of consciousness are NICE compliant nor does it ensure that staff conduct clinical investigations of prisoners who experience such episodes . It should be remembered here that Doctors saw Lee Terence Curran on five occasions following episodes of loss of consciousness and the NICE guidelines were not followed at any time.
” 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 Sodexo; that does not assign responsibility.
PFD Monitor interpretation Failure to take full account of family history when clinically investigating prisoners with possible high cholesterol
Wider context from the report “(1) The Prisons and Probation Ombudsman investigated Lee Terence Curran’s death. At the conclusion of that investigation certain recommendations were made, two of which were as follows:
a. “The Head of Healthcare should ensure that healthcare staff take full account of family history when arranging clinical investigations for prisoners who report, or are observed to have possible signs of high cholesterol or hypertension”.
b. “The Head of Healthcare should develop a protocol that is NICE compliant for investigating episodes of loss of consciousness and should ensure that staff conduct clinical investigations of prisoners who experience such episodes.”
Both of these recommendations were accepted. However the evidence given at the Inquest in relation to the implementation of recommendation a. was that all prisoners coming to Forest Bank Prison undertake the reception screening process and any prisoner with any identified, or any sign of, hypertension is referred to the hypertension clinic. A full account of the prisoner’s family history is then taken at that clinic. There was no evidence that any action had been taken to address that part of the Ombudsman’s recommendation that related to prisoners (such as Lee Terence Curran) who reported or showed signs of having high cholesterol.
Likewise with recommendation b. The evidence given at the Inquest with regard to the implementation of that recommendation was that any individual who had a loss of consciousness would be automatically referred to a Doctor. That action does not encompass the whole of the Ombudsman’s recommendation. Particularly it does not ensure that investigations of episodes of loss of consciousness are NICE compliant nor does it ensure that staff conduct clinical investigations of prisoners who experience such episodes. It should be remembered here that Doctors saw Lee Terence Curran on five occasions following episodes of loss of consciousness and the NICE guidelines were not followed at any time.
” 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 Sodexo; that does not assign responsibility.
PFD Monitor interpretation Lack of doctors’ awareness of NICE guidelines for transient loss of consciousness
Wider context from the report “(3) Evidence given at the Inquest also revealed a need for the training of Doctors working in prisons in that Doctors who provided general practice sessions at the prison (and in the community) gave evidence that they were unaware of the NICE Guidelines for Transient Loss of Consciousness Management in Adults and Young People despite such episodes being common in a prison environment . Additionally evidence was given by a Doctor that efforts were not made to fully investigate Lee Terence Curran’s episodes of loss of consciousness because, the Doctor explained, it was common for prisoners to claim to have suffered losses of consciousness as a form of drug seeking behaviour.
” Open source report
Pin
Request correction
Addressed to: Sodexo Justice Services.
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations