Recipient

Stoke Heath Prison

First report 21 Apr 2016•Latest report 14 Apr 2023

Recipient record

Reports, concerns and published responses

Justice · Prison or young offender institution. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 3
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

0%published responses found

0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

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

14 Apr2023
Staffordshire and Stoke on Trent
Concerns raised2
1. Failure to ensure access to GP and community mental health services for people released from prison
2. Lack of accommodation for people released from prison
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

Mr Darren Clifford Docherty · 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

Mr Darren Clifford Docherty was released from HMP Stoke Heath without accommodation and was subsequently found hanging from a tree on 10 August 2023. The report raised concern that people released from prison without accommodation may be unable to access GP and community mental health services.

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 Stoke Heath Prison; that does not assign responsibility.
PFD Monitor interpretation
Failure to ensure access to GP and community mental health services for people released from prison
Wider context from the report
“1. That when people are released from prison they do so, on many occasions, with no accommodation. Those that need GP access and community mental health services are unable to access them in these circumstances. ”
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 Stoke Heath Prison; that does not assign responsibility.
PFD Monitor interpretation
Lack of accommodation for people released from prison
Wider context from the report
“1. That when people are released from prison they do so, on many occasions, with no accommodation. Those that need GP access and community mental health services are unable to access them in these circumstances. ”
Open source report
1 Aug2018
Shropshire, Telford and Wrekin
Concerns raised3
1. Lack of policy or guidance for additional checks of prisoners with repeated NPS use
2. Failure to communicate elevated NPS-related risk to Healthcare and prison officers
3. Unavailability of relevant prisoner medical information to drug workers
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

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 Stoke Heath Prison; 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 Stoke Heath Prison; 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 Stoke Heath Prison; 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
21 Apr2016
Shropshire, Telford and Wrekin
Concerns raised5
1. Failure to provide or record support for prisoners reporting bullying without naming alleged perpetrators
2. Failure to investigate allegations of bullying
3. Insufficient first-aid training among first-attending prison officers
1. Ineffective implementation of the Tackling Bullying Behaviour policy in response to bullying complaints
2. Failure to refer concerns to a MASH meeting when risk indicators are present
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

Derrick Edward ROSE-FOWLER · 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

Derrick Edward ROSE-FOWLER was found hanging by his neck from his prison cell window on 5 June 2015 and was pronounced dead after being transferred to hospital. The concerns included the first attending prison officer not being first-aid trained, the handling of alleged bullying, and the failure to raise concerns about the deceased at a MASH meeting despite several relevant factors.

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 Stoke Heath Prison; that does not assign responsibility.
PFD Monitor interpretation
Failure to provide or record support for prisoners reporting bullying without naming alleged perpetrators
Wider context from the report
“(2) The TBB did not explicitly allow for or record that a prisoner, such as the deceased, who was not prepared to name names could nevertheless still be offered support. It is a concern that the reasons given by the various witnesses were not demonstrated to have been considered. ”
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 Stoke Heath Prison; that does not assign responsibility.
PFD Monitor interpretation
Failure to investigate allegations of bullying
Wider context from the report
“(3) At paragraph 19 of the final PPO report it states ‘there has been one other self-inflicted death at Stoke Heath, in the last 4 years – in March 2013. In the investigation into that death we found that the prison did not investigate allegations of bullying’. For completeness the central issue at that inquest was in relation to the deceased’s mental health. ”
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 Stoke Heath Prison; that does not assign responsibility.
PFD Monitor interpretation
Insufficient first-aid training among first-attending prison officers
Wider context from the report
“(1) Although on the facts of this case it made no difference to the outcome, the first prison officer on the scene was not first aid trained. The evidence at the inquest was that there was no national requirement for all prison officers to be first aid trained provided a certain proportion were. (2) In hanging cases time is of the essence for CPR and if there is any significant delay by reason of the first attending prison officer not being first aid trained there is the risk of future deaths occurring. ”
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 Stoke Heath Prison; that does not assign responsibility.
PFD Monitor interpretation
Ineffective implementation of the Tackling Bullying Behaviour policy in response to bullying complaints
Wider context from the report
“(1) There was evidence that bullying was ‘rife’. Whilst the majority of the evidence at the inquest indicated that the deceased was not himself being bullied there was some evidence that he was. The prison has a Tackling Bullying Behaviour (TBB) policy but there is concern as to how effective it was implemented on the complaints raised by the deceased himself that he was, in terms, being bullied. ”
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 Stoke Heath Prison; that does not assign responsibility.
PFD Monitor interpretation
Failure to refer concerns to a MASH meeting when risk indicators are present
Wider context from the report
“(4) Regardless of whether the TBB policy was appropriately implemented there was evidence that concerns relating to the deceased should have been raised at a MASH meeting. Factors which should have triggered such a referral were: a. History of self-harm in 2014. b. Recorded diagnoses of anxiety and depression. c. An ACCT opened at HMP Featherstone in October 2014. d. The intelligence report raised by the mental health nurse in March 2015. e. The letter handed by the deceased to a prison officer in April 2015. f. The refusal of the deceased to take prescribed medication. g. The refusal of the deceased to attend scheduled GP appointments. It could not be said that any such referral would have changed the outcome but there was evidence that something would have been done. ”
Open source report

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

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised2

Failure to ensure access to GP and community mental health services for people released from prison

Lack of accommodation for people released from prison

Concerns raised3

Lack of policy or guidance for additional checks of prisoners with repeated NPS use

Failure to communicate elevated NPS-related risk to Healthcare and prison officers

Unavailability of relevant prisoner medical information to drug workers

Concerns raised5

Failure to provide or record support for prisoners reporting bullying without naming alleged perpetrators

Failure to investigate allegations of bullying

Insufficient first-aid training among first-attending prison officers

Ineffective implementation of the Tackling Bullying Behaviour policy in response to bullying complaints

Failure to refer concerns to a MASH meeting when risk indicators are present