7 Apr 2026 Mark Robert Smith · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 9 Failure to ensure truthful observation records View source Failure to maintain QEH staff awareness of the limits of prison healthcare View source Failure to coordinate prison discharge through an MDT and relevant prison healthcare liaison View source Failure to prescribe and administer medication at the correct dose View source Failure to ensure safe and clearly understood medication-system operation View source Failure to record the cell-entry escalation process in policy View source Failure to maintain prison and healthcare staff awareness of the cell-entry escalation process View source Failure to complete required patient observations View source Unavailability of larger disabled cells adapted for constant watch View source See 6 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.
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AI-generated summary
Mark Robert Smith · 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
Mark Robert Smith, who was detained at HMP Thameside, died after an epileptic seizure led to cardiac arrest. The report describes concerns about medication prescribing and administration, hospital-to-prison discharge and communication, access to his cell, observation arrangements and records, staffing, and the lack of equipment for resuscitation.
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 Thameside Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure truthful observation records
Wider context from the report “(5) I am concerned there were numerous missed and falsified observation entries in Mark’s case and how similar incidents can be prevented given the reliance on handwritten sheets being scanned onto the system at a later stage . I appreciate the efforts made with training and audits. (Practice Plus Group)
” 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 Thameside Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain QEH staff awareness of the limits of prison healthcare
Wider context from the report “(2) I remain concerned a similar situation could arise as did in Mark’s case regarding a discharge back to prison from QEH without an MDT meeting despite repeated requests from prison healthcare and there could be a risk to life. I note PFD evidence provided regarding improved liaison between QEH and the prison GP but note no reference to liaison between QEH and the head of the healthcare in prison, who visited QEH twice in Mark’s case.
Further, as recently as 2025 an incident occurred when there was a lack of understanding at QEH around the limited provision in healthcare in prison . I am concerned as to how awareness of the limits of prison healthcare will be disseminated on a continuing basis to new and locum staff at QEH . (QEH and Practice Plus Group)
” 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 Thameside Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to coordinate prison discharge through an MDT and relevant prison healthcare liaison
Wider context from the report “(2) I remain concerned a similar situation could arise as did in Mark’s case regarding a discharge back to prison from QEH without an MDT meeting despite repeated requests from prison healthcare and there could be a risk to life. I note PFD evidence provided regarding improved liaison between QEH and the prison GP but note no reference to liaison between QEH and the head of the healthcare in prison , who visited QEH twice in Mark’s case.
Further, as recently as 2025 an incident occurred when there was a lack of understanding at QEH around the limited provision in healthcare in prison. I am concerned as to how awareness of the limits of prison healthcare will be disseminated on a continuing basis to new and locum staff at QEH. (QEH and Practice Plus Group)
” 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 Thameside Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to prescribe and administer medication at the correct dose
Wider context from the report “(1) The wrong dose of medication could be prescribed and/or administered with life threatening consequences. Albeit I have seen evidence of significant improvements in prescribing practice at HMP Thameside since 2019 (e.g HMIP report February 2026); as recently as 2024 to 2025 HMIP and IMB reports noted “significant risks with management of medicines” and “prescribing errors.” Whilst recent internal audits in 2025 show significant improvements, medication incidents (datix) are recorded in late 2025 and the principal pharmacist notes a very busy site with multiple prescriptions screened daily.
Further, during the inquest it proved difficult to establish how Systm 1 (the medical note system) operated and whether there were risks inherent in the system itself. For example, it was suggested the system would convert mg into ml or pre-populate entries such as 100ml, in contradiction to the subsequent PFD evidence provided. (Practice Plus Group)
” 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 Thameside Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure safe and clearly understood medication-system operation
Wider context from the report “(1) The wrong dose of medication could be prescribed and/or administered with life threatening consequences. Albeit I have seen evidence of significant improvements in prescribing practice at HMP Thameside since 2019 (e.g HMIP report February 2026); as recently as 2024 to 2025 HMIP and IMB reports noted “significant risks with management of medicines” and “prescribing errors.” Whilst recent internal audits in 2025 show significant improvements, medication incidents (datix) are recorded in late 2025 and the principal pharmacist notes a very busy site with multiple prescriptions screened daily.
Further, during the inquest it proved difficult to establish how Systm 1 (the medical note system) operated and whether there were risks inherent in the system itself . For example, it was suggested the system would convert mg into ml or pre-populate entries such as 100ml , in contradiction to the subsequent PFD evidence provided. (Practice Plus Group)
” 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 Thameside Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to record the cell-entry escalation process in policy
Wider context from the report “(3) Healthcare staff may be unable to enter a prisoner’s cell at night and monitor them in a situation which may not constitute a “medical emergency” but in which a patient nevertheless requires attention; a patient could decline and the situation become life threatening. I have received detail from Serco of “an escalation process” if Oscar 1 and Hotel 1 cannot agree about entry to a cell and I have been told this has been “recommunicated” to all staff. However, this is not recorded in a policy. I am concerned about awareness of the process for all prison and healthcare staff including on an ongoing basis. (Serco and Practice Plus Group).
” 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 Thameside Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain prison and healthcare staff awareness of the cell-entry escalation process
Wider context from the report “(3) Healthcare staff may be unable to enter a prisoner’s cell at night and monitor them in a situation which may not constitute a “medical emergency” but in which a patient nevertheless requires attention; a patient could decline and the situation become life threatening. I have received detail from Serco of “an escalation process” if Oscar 1 and Hotel 1 cannot agree about entry to a cell and I have been told this has been “recommunicated” to all staff. However, this is not recorded in a policy. I am concerned about awareness of the process for all prison and healthcare staff including on an ongoing basis. (Serco and Practice Plus Group).
” 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 Thameside Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to complete required patient observations
Wider context from the report “(5) I am concerned there were numerous missed and falsified observation entries in Mark’s case and how similar incidents can be prevented given the reliance on handwritten sheets being scanned onto the system at a later stage. I appreciate the efforts made with training and audits. (Practice Plus Group)
” 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 Thameside Prison; that does not assign responsibility.
PFD Monitor interpretation Unavailability of larger disabled cells adapted for constant watch
Wider context from the report “(4) There are no larger disabled cells (which can accommodate hospital beds and wheelchairs) adapted to also facilitate a constant watch. Security concerns, in this might not be possible, and a similar situation might occur to that in Mark’s case. (HMPPS)
” Open source report
12 Oct 2023 Mr Jonathan Michael McCarthy · Prevention of Future Deaths report Northamptonshire
View report summary
Concerns raised 4 Failure to determine the clinical importance and urgency of pre-existing community hospital appointments in light of security issues View source Failure to verify prisoners’ pre-existing community hospital appointments View source Failure to determine medical hold View source Failure to assess fitness to transfer View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Mr Jonathan Michael McCarthy · 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 Jonathan Michael McCarthy died on 12 August 2018 at University Hospital Coventry and Warwickshire from a cardiac arrhythmia associated with scarring of the heart, while at HMP Onley. Concerns included failures to verify and assess the clinical importance of pre-existing community hospital appointments, the impact of security issues on those appointments, and whether he was fit to transfer or should have been placed on medical hold.
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 Thameside Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to determine the clinical importance and urgency of pre-existing community hospital appointments in light of security issues
Wider context from the report “Upon Mr McCarthy’s arrival at HMP Altcourse on 5 June 2017, it is recorded that he had an outstanding hospital appointment. There was no evidence that HMP Altcourse took any steps to verify this appointment.
Mr McCarthy was transferred to HMP Thameside on 7 May 2018. It is recorded that he had an appointment to see the cardiologist at Whittington Hospital on 13 June 2018. There was no evidence that HMP Thameside took any steps to verify this appointment. He was transferred from the prison on the next day, 14th June 2018.
It was suggested in evidence that HMP Thameside automatically re-arrange all community medical appointments for security reasons. It was clarified that the prison would only try to get a new appointment if there was a specific security concern.
There was also no evidence that Mr McCarthy had a fitness to transfer assessment at either HMP Altcourse or HMP Thameside.
1. verifying a prisoner’s pre-existing community hospital appointments.
2. determining the clinical importance/urgency of pre-existing community hospital appointments and the impact of security issues upon this assessment.
3. assessing fitness to transfer and determining medical hold.
” 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 Thameside Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to verify prisoners’ pre-existing community hospital appointments
Wider context from the report “Upon Mr McCarthy’s arrival at HMP Altcourse on 5 June 2017, it is recorded that he had an outstanding hospital appointment. There was no evidence that HMP Altcourse took any steps to verify this appointment.
Mr McCarthy was transferred to HMP Thameside on 7 May 2018. It is recorded that he had an appointment to see the cardiologist at Whittington Hospital on 13 June 2018. There was no evidence that HMP Thameside took any steps to verify this appointment. He was transferred from the prison on the next day, 14th June 2018.
It was suggested in evidence that HMP Thameside automatically re-arrange all community medical appointments for security reasons. It was clarified that the prison would only try to get a new appointment if there was a specific security concern.
There was also no evidence that Mr McCarthy had a fitness to transfer assessment at either HMP Altcourse or HMP Thameside.
1. verifying a prisoner’s pre-existing community hospital appointments.
2. determining the clinical importance/urgency of pre-existing community hospital appointments and the impact of security issues upon this assessment.
3. assessing fitness to transfer and determining medical hold.
” 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 Thameside Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to determine medical hold
Wider context from the report “Upon Mr McCarthy’s arrival at HMP Altcourse on 5 June 2017, it is recorded that he had an outstanding hospital appointment. There was no evidence that HMP Altcourse took any steps to verify this appointment.
Mr McCarthy was transferred to HMP Thameside on 7 May 2018. It is recorded that he had an appointment to see the cardiologist at Whittington Hospital on 13 June 2018. There was no evidence that HMP Thameside took any steps to verify this appointment. He was transferred from the prison on the next day, 14th June 2018.
It was suggested in evidence that HMP Thameside automatically re-arrange all community medical appointments for security reasons. It was clarified that the prison would only try to get a new appointment if there was a specific security concern.
There was also no evidence that Mr McCarthy had a fitness to transfer assessment at either HMP Altcourse or HMP Thameside.
1. verifying a prisoner’s pre-existing community hospital appointments.
2. determining the clinical importance/urgency of pre-existing community hospital appointments and the impact of security issues upon this assessment.
3. assessing fitness to transfer and determining medical hold.
” 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 Thameside Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to assess fitness to transfer
Wider context from the report “Upon Mr McCarthy’s arrival at HMP Altcourse on 5 June 2017, it is recorded that he had an outstanding hospital appointment. There was no evidence that HMP Altcourse took any steps to verify this appointment.
Mr McCarthy was transferred to HMP Thameside on 7 May 2018. It is recorded that he had an appointment to see the cardiologist at Whittington Hospital on 13 June 2018. There was no evidence that HMP Thameside took any steps to verify this appointment. He was transferred from the prison on the next day, 14th June 2018.
It was suggested in evidence that HMP Thameside automatically re-arrange all community medical appointments for security reasons. It was clarified that the prison would only try to get a new appointment if there was a specific security concern.
There was also no evidence that Mr McCarthy had a fitness to transfer assessment at either HMP Altcourse or HMP Thameside.
1. verifying a prisoner’s pre-existing community hospital appointments.
2. determining the clinical importance/urgency of pre-existing community hospital appointments and the impact of security issues upon this assessment.
3. assessing fitness to transfer and determining medical hold.
” Open source report
25 Aug 2023 Stephen Weatherley · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 3 Absence of written guidance for suspected drug swallow assessment, referral and monitoring View source Inadequate MOJ oversight and monitoring of recording and retention of data View source Failure to maintain and retain complete contemporaneous records and documents View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Stephen Weatherley · 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
Stephen Weatherley died at HMP Thameside from the toxic effects of cocaine and methadone after swallowing a package containing a drug during a prison visit. The report identifies concerns about the visitor being allowed an open visit, inadequate investigation and monitoring after the visit, poor record keeping and data retention, and the absence of written guidance for suspected drug swallows.
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 Thameside Prison; that does not assign responsibility.
PFD Monitor interpretation Absence of written guidance for suspected drug swallow assessment, referral and monitoring
Wider context from the report “Absence of a written policy at HMP Thameside if there is a suspected drug swallow.
15. In 2018, there was no written policy as to what should occur where there may have been a drugs swallow but it had not been seen immediately by staff or on CCTV. That remains the case.
16. In SW’s case, the body scanner had not been installed in 2018 and following a search of SW and review of the CCTV he was returned to the wing (and not taken CSU or healthcare). The jury found that there was insufficient investigation after the visit and a lack of implementation of precautionary measures.
17. I was informed by HMP Thameside on 12th June 2023, that in a similar situation the prisoner would now be scanned using the body scanner. If the prisoner had concealed an item in a bodily orifice he would be taken to CSU. If he had swallowed an item, he would be taken to Healthcare. I was told this is standard practice but is not written down. Further, if a prisoner refused a scan, he would be taken to CSU. The management of the prisoner in CSU would be the subject of an algorithm deployed by Healthcare, which then produced guidance as to monitoring. There would be liaison between Healthcare and CSU to ensure the prisoner was appropriately monitored.
18. At present the system relies upon good communications/decision making between healthcare and discipline staff and individual judgement.
19. I remain concerned as to the absence of written guidance for officers and the risk that if they are not aware of the above “informal” guidance, a prisoner may not be taken to the correct location (CSU or Healthcare) and/or there may not be appropriate monitoring . I appreciate that each situation is fact specific and drafting written guidance may be difficult.
” 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 Thameside Prison; that does not assign responsibility.
PFD Monitor interpretation Inadequate MOJ oversight and monitoring of recording and retention of data
Wider context from the report “Data recording and retention in HMP Thameside/oversight by MOJ
1. Key documents around decision making by Serco officers in respect of open/closed visits for SW were lost.
2. Record keeping of key events on 23rd and 24th February 2018 was not properly completed by Serco officers on the central system for recording, operated by the MOJ (“PNOMIS”).
3. There were only 3 entries on SW’s PNOMIS record in the 5 months he was at HMP Thameside.
4. The PPO investigator encountered delays in obtaining documents, unclear and incomplete records from HMP Thameside. The decision making around closed visits/reviews was requested by the PPO in September 2018 and had not been provided at the time the PPO report in April 2019, which pre-dated the electronic migration of data in October 2020 (see below).
5. Solicitors representing HMP Thameside informed me on 30 March 2023 that the prison was unable to adduce the 2018 versions of the local standard operating procedures in place at the time of SW’s death (i.e re visits procedures) due to a large IT migration which took place around 18 months prior (October 2020), which resulted in the loss of some historical data saved on their systems.
6. I subsequently requested the underlying decision making around closed visits/review (as I had the PPO before me) and was informed that these documents were no longer available, also lost in the electronic migration.
7. I was then informed (during the Inquest), that material may have been lost due to officers storing it on local desktop computers and not uploading it to the main system.
8. Having expressed concerns about record-keeping and data retention, I heard PFD evidence on 12th June 2023 about a limited internal audit of PNOMIS which revealed concerns over 15% of the records reviewed. I heard evidence that contract managers oversee the contract between the MOJ and Serco, reporting monthly on contract delivery indicators. They do not conduct specific checks on PNOMIS record keeping/audits of the same.
9. I also heard evidence on 12th June 2023 that there remain two systems for record keeping, the Serco system, CMS and the national MOJ system, PNOMIS. CMS requires a layer of officer input (uploading and/or printing off) to ensure retention and distribution. A notice to staff dated 23rd June 2023 reminded them to upload material to CMS.
10. A witness statement from the director of HMP Thameside dated 26th June 2023 further explained the contractual relationship between the MOJ and Serco including the 28 contract delivery indicators. There is also a contractual requirement to ensure compliance with Prison Service Instructions (PSIs) which include PSI 04/2018 which relates to records, information management and retention policy.
11. In this witness statement, the director stated that he had instructed the Serco Assurance Team (independent of the prison team) to conduct a widespread audit of the PNOMIS and Death in Custody files, which will be completed by September 2023. Whilst I am reassured that an independent audit is being conducted, the results are not currently available. SW died in 2018 and the audit was not initiated until June 2023.
12. I accept that there have been improvements. However, given the extent and impact of the deficiencies outlined above, I remain concerned as to whether systems (for both record keeping and retention) have improved sufficiently since 2018.
13. I am also concerned as to the level of oversight and monitoring by the MOJ (having subcontracted to Serco) of recording and retention of data , given that key data was lost, key records were not maintained and the PPO was not provided with documents requested.
14. If key documents are not available/incidents are not recorded contemporaneously, then the PPO and the Inquest process is frustrated. It is more difficult to identify deficiencies and prevent future deaths. Further, if communications are not recorded, there is a risk that relevant factors are not considered when officers are making potentially life-impacting decisions.
” 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 Thameside Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain and retain complete contemporaneous records and documents
Wider context from the report “Data recording and retention in HMP Thameside/oversight by MOJ
1. Key documents around decision making by Serco officers in respect of open/closed visits for SW were lost.
2. Record keeping of key events on 23rd and 24th February 2018 was not properly completed by Serco officers on the central system for recording, operated by the MOJ (“PNOMIS”).
3. There were only 3 entries on SW’s PNOMIS record in the 5 months he was at HMP Thameside.
4. The PPO investigator encountered delays in obtaining documents, unclear and incomplete records from HMP Thameside. The decision making around closed visits/reviews was requested by the PPO in September 2018 and had not been provided at the time the PPO report in April 2019, which pre-dated the electronic migration of data in October 2020 (see below).
5. Solicitors representing HMP Thameside informed me on 30 March 2023 that the prison was unable to adduce the 2018 versions of the local standard operating procedures in place at the time of SW’s death (i.e re visits procedures) due to a large IT migration which took place around 18 months prior (October 2020), which resulted in the loss of some historical data saved on their systems.
6. I subsequently requested the underlying decision making around closed visits/review (as I had the PPO before me) and was informed that these documents were no longer available, also lost in the electronic migration.
7. I was then informed (during the Inquest), that material may have been lost due to officers storing it on local desktop computers and not uploading it to the main system.
8. Having expressed concerns about record-keeping and data retention, I heard PFD evidence on 12th June 2023 about a limited internal audit of PNOMIS which revealed concerns over 15% of the records reviewed. I heard evidence that contract managers oversee the contract between the MOJ and Serco, reporting monthly on contract delivery indicators. They do not conduct specific checks on PNOMIS record keeping/audits of the same.
9. I also heard evidence on 12th June 2023 that there remain two systems for record keeping, the Serco system, CMS and the national MOJ system, PNOMIS. CMS requires a layer of officer input (uploading and/or printing off) to ensure retention and distribution. A notice to staff dated 23rd June 2023 reminded them to upload material to CMS.
10. A witness statement from the director of HMP Thameside dated 26th June 2023 further explained the contractual relationship between the MOJ and Serco including the 28 contract delivery indicators. There is also a contractual requirement to ensure compliance with Prison Service Instructions (PSIs) which include PSI 04/2018 which relates to records, information management and retention policy.
11. In this witness statement, the director stated that he had instructed the Serco Assurance Team (independent of the prison team) to conduct a widespread audit of the PNOMIS and Death in Custody files, which will be completed by September 2023. Whilst I am reassured that an independent audit is being conducted, the results are not currently available. SW died in 2018 and the audit was not initiated until June 2023.
12. I accept that there have been improvements. However, given the extent and impact of the deficiencies outlined above, I remain concerned as to whether systems (for both record keeping and retention) have improved sufficiently since 2018.
13. I am also concerned as to the level of oversight and monitoring by the MOJ (having subcontracted to Serco) of recording and retention of data, given that key data was lost, key records were not maintained and the PPO was not provided with documents requested.
14. If key documents are not available/incidents are not recorded contemporaneously, then the PPO and the Inquest process is frustrated. It is more difficult to identify deficiencies and prevent future deaths. Further, if communications are not recorded , there is a risk that relevant factors are not considered when officers are making potentially life-impacting decisions.
” 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 Complete an independent audit of document retention in death-in-custody cases.
Verbatim wording from the response “It was indicated by me that I attend a Quarterly Contract Review Meeting with the MOJ controllers and we discuss findings from the PPO investigations. Nonetheless, an independent audit of the retention of documents on the DIC cases was instructed from the Assurance Team (part of the Serco Enterprise Risk Management team) and reporting to UK&I General Counsel of Serco. It was confirmed that this is independent to the Prison and arrangements for this are underway, with an expected completion date of September 2023. The difficulty with the case of SW was that it had been delayed for a number of years (to some extent due to the criminal liability for SW's visitors) so the management of the DIC's had long since improved and the Prison had no cause for concern in relation to the DIC information retention since my appointment three years ago.” Source location Response from Serco
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement written security guidance governing body-scanner use and recording of scans.
Verbatim wording from the response “In terms of Concern Two, there is a written Serco Custodial Security Strategy ("SCSS") dated July 2021 which outlines when a prisoner can be put through the bodyscanner and it incorporates the national policy 'Use of X-ray Body Scanners (Adult Male Prisons)' dated 18 May 2022 and reissued 3 October 2022¹ which states:” Source location Response from Serco
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish and maintain MS Teams folders to retain death-in-custody information and provide required documents.
Verbatim wording from the response “Firstly, in relation to data retention following a Death in Custody ("DIC"), Assistant Director ("AD") ████████ provided evidence at the Inquest that he now has autonomy of this process and that there is now a system in place whereby he has set up MS Teams folders which contain all the relevant information, in accordance national PSI's. ████████ was candid in accepting that he could not explain why documents weren't provided to the Prison and Probation Ombudsman ("PPO") back in 2018 (before he was in post) as the relevant staff members were no longer employed by Serco. However in any circumstance since, he has personally provided the PPO with the information required to further their investigations.” Source location Response from Serco
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct an independent review of a wider selection of PNOMIS files.
Verbatim wording from the response “A small audit was completed by ████████ in short order to assist you with your concerns before 12 June 2023. However, as provided in my statement dated 26 June 2023, the Prison have instructed the same Serco independent audit team to conduct an independent review of a wider selection of PNOMIS files. Again, arrangement are in place to have this completed by September 2023 and we understand that our legal team, DWF LLP, offered to share the results of the same with you on our behalf. It is understood that this offer was made in email correspondence on 05 July 2023.” Source location Response from Serco
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Disseminate the inquest and report learning to prison senior management, advising relocation to healthcare where suspected swallowing lacks a positive scan.
Verbatim wording from the response “We can confirm that we will be sharing the learnings of this Inquest and indeed the contents of the Report with the senior management team within the Prison and preface with advice that where there is a suspected 'swallow' and absence of a positive bodyscanner result, they should re-locate to healthcare.” Source location Response from Serco
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 Existing MS Teams, SharePoint, PNOMIS, QA audits and management safeguards are considered sufficient for retaining and recording death-in-custody information.
Verbatim wording from the response “Firstly, in relation to data retention following a Death in Custody ("DIC"), Assistant Director ("AD") ████████ provided evidence at the Inquest that he now has autonomy of this process and that there is now a system in place whereby he has set up MS Teams folders which contain all the relevant information, in accordance national PSI's. ████████ was candid in accepting that he could not explain why documents weren't provided to the Prison and Probation Ombudsman ("PPO") back in 2018 (before he was in post) as the relevant staff members were no longer employed by Serco. However in any circumstance since, he has personally provided the PPO with the information required to further their investigations.” Source location Response from Serco
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 Existing SCSS and national policy provide written guidance for body scanning, suspected swallowing, refusal, monitoring and healthcare involvement.
Verbatim wording from the response “In terms of Concern Two, there is a written Serco Custodial Security Strategy ("SCSS") dated July 2021 which outlines when a prisoner can be put through the bodyscanner and it incorporates the national policy 'Use of X-ray Body Scanners (Adult Male Prisons)' dated 18 May 2022 and reissued 3 October 2022¹ which states:” Source location Response from Serco
Open published response
29 Oct 2018 Mr Thomas Patrick McAuley · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 7 Failure to provide prison doctors access to uploaded prison case history notes View source Failure to ensure universal availability of DPMFs to health care staff View source Failure to ensure sufficient time for reception nurses to review DPMFs View source Failure of police doctors to communicate directly with prison health care staff or transfer medical information between doctors View source Failure to establish a fail-safe mechanism for medical staff in prison to see and consider custody assessments and records View source Failure to provide DPMFs to health care staff View source Unavailability of DPMFs in prison wings 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
Mr Thomas Patrick McAuley · 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 Thomas Patrick McAuley was found dead in his prison cell on 23 August 2017. The medical cause of death was bronchopneumonia, with chronic bronchitis and alcohol and drug dependence also recorded. The inquest identified concerns about clinical information from police custody not being available to all prison clinical staff and a lack of clinical observations during the first five days of methadone treatment.
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 Thameside Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to provide prison doctors access to uploaded prison case history notes
Wider context from the report “3. An Oxleas manager said that the case history notes from the prison were uploaded onto PNomis, but a prison doctor did not think he had access to 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 Thameside Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure universal availability of DPMFs to health care staff
Wider context from the report “4. A representative of Oxleas HC reported that a new process required a nurse to tick a box when the DPMF was uploaded onto the medical records, but there was no evidence that the DPMF is universally available to health care staff .
” 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 Thameside Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure sufficient time for reception nurses to review DPMFs
Wider context from the report “1. The reception nurse said that she would have had access to DPMFs but does not always have time to look at these . The DPMF was not available in the wings.
” 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 Thameside Prison; that does not assign responsibility.
PFD Monitor interpretation Failure of police doctors to communicate directly with prison health care staff or transfer medical information between doctors
Wider context from the report “5. There was no evidence that police doctors communicated directly with health care staff in prison , or arranged for transfer of medical information between doctors . (The police doctors were not called).
” 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 Thameside Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to establish a fail-safe mechanism for medical staff in prison to see and consider custody assessments and records
Wider context from the report “6. In conclusion, there is no assurance that doctors attending in custody, the prison service and those providing health care in prisons have established a fail-safe mechanism of ensuring that medical assessments on vulnerable individuals and records from custody are seen and considered by medical staff in prison .
” 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 Thameside Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to provide DPMFs to health care staff
Wider context from the report “2. A manager of the drug addiction services in the prison said that health care staff were not always given the DPMF .
” 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 Thameside Prison; that does not assign responsibility.
PFD Monitor interpretation Unavailability of DPMFs in prison wings
Wider context from the report “1. The reception nurse said that she would have had access to DPMFs but does not always have time to look at these. The DPMF was not available in the wings .
” Open source report
19 Sep 2014 Satheeskumar MAHATHEVAN · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 6 Failure of multi-agency communication procedures View source Failure of multi-agency communication procedures View source Failures in information sharing View source Inadequate training for prison service staff View source Inadequate staff training in prison services View source Failure of information sharing 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.
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AI-generated summary
Satheeskumar MAHATHEVAN · 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
Satheeskumar Mahathevan hanged himself in his cell at HM Prison Pentonville on 14 April 2013. The report identified concerns about failures in information sharing, multi-agency communication procedures, and inadequate training for prison staff.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Thameside Prison; that does not assign responsibility.
PFD Monitor interpretation Failure of multi-agency communication procedures
Wider context from the report ““Failures in relation to information sharing, multi agency communication procedures and inadequate training for staff at the prison services have contributed to this accident.”
” 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 Thameside Prison; that does not assign responsibility.
PFD Monitor interpretation Failure of multi-agency communication procedures
Wider context from the report ““Failures in relation to information sharing, multi agency communication procedures and inadequate training for staff at the prison services have contributed to this accident.”
” 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 Thameside Prison; that does not assign responsibility.
PFD Monitor interpretation Failures in information sharing
Wider context from the report ““Failures in relation to information sharing , multi agency communication procedures and inadequate training for staff at the prison services have contributed to this accident.”
” 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 Thameside Prison; that does not assign responsibility.
PFD Monitor interpretation Inadequate training for prison service staff
Wider context from the report ““Failures in relation to information sharing, multi agency communication procedures and inadequate training for staff at the prison services have contributed to this accident.”
” 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 Thameside Prison; that does not assign responsibility.
PFD Monitor interpretation Inadequate staff training in prison services
Wider context from the report ““Failures in relation to information sharing, multi agency communication procedures and inadequate training for staff at the prison services have contributed to this accident.”
” 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 Thameside Prison; that does not assign responsibility.
PFD Monitor interpretation Failure of information sharing
Wider context from the report ““Failures in relation to information sharing , multi agency communication procedures and inadequate training for staff at the prison services have contributed to this accident.”
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations