Recipient

The Forward Trust

First report 1 Aug 2018•Latest report 13 Nov 2023

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Company limited by guarantee. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 4
Published responses: 25%
Concerns addressed: 0
Stated actions: 5

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.

25%published responses found

5stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from The Forward Trust linked to the concerns in each report. Select any concern, action or position to view the source wording.

13 Nov2023
Essex
Concerns raised1
1. Failure to document and embed the drug detoxification discharge pathway in operating procedures
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

John Paul Pace · 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

John Paul Pace was serving a prison sentence at HMP Chelmsford and was receiving methadone as part of a drug detoxification programme. He stopped taking methadone before completing the programme and was found unresponsive at the prison on 22 July 2020; the post-mortem examination concluded that the likely medical cause of death was synthetic cannabinoid misuse. The principal concern was that a new discharge pathway for prisoners who stopped or completed methadone detoxification had not been documented in policies or procedures, creating a risk that monitoring and support would not be provided consistently.

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 The Forward Trust; that does not assign responsibility.
PFD Monitor interpretation
Failure to document and embed the drug detoxification discharge pathway in operating procedures
Wider context from the report
“One of the material issues in evidence was about changes in the discharge pathway for prisoners on methadone detoxification as well as those who decided to stop the detoxification programme before completion. CRG identified the need for this change in their Root Cause Analysis review and their live witnesses provided evidence that this new process is now being followed. Forward Trust provided evidence that this is the new process now embedded in their operating procedure. However, no documentary evidence of this new drug detoxification discharge pathway seems to exist, no protocols, no written procedures, no policy, no addendum to existing policies and procedures. It is my concern that this new discharge pathway aimed at providing monitoring and support to prisoners who stop or complete the programme whilst in prison, has not been embedded in your organisations’ operating procedure and as such, there is a risk to prisoners in the future as compliance with the new discharge pathway and consistency of operations cannot be ensured. ”
Open source report
21 Aug2023
West London
Concerns raised4
1. Lack of clear options and forward planning after failure of an assistance plan
2. Insufficient staff training for dealing with complex hoarder cases
3. Council hoarder-support guidance failing to support tenant assistance
1. Failure to request required fire and environmental health assessments
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

Jacqueline Elizabeth 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

Jacqueline Elizabeth Smith took her own life by overdosing on prescribed medication at home and died in Hillingdon Hospital on 12 August 2022. She had poor physical health and considerable anxiety while seeking council assistance with hoarded possessions, and a mental health assessment was not performed after she contacted a crisis telephone service. The inquest identified concerns including insufficient staff training for complex hoarder cases, missing safety assessments, an unsuitable council flow chart, and a lack of clear options after the initial assistance plan failed.

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 The Forward Trust; that does not assign responsibility.
PFD Monitor interpretation
Lack of clear options and forward planning after failure of an assistance plan
Wider context from the report
“(4) It was entirely unclear what options were available (if any) when the first plan of assistance completely failed, leaving the vulnerable tenant excluded from her property with no forward plan. ”
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 The Forward Trust; that does not assign responsibility.
PFD Monitor interpretation
Insufficient staff training for dealing with complex hoarder cases
Wider context from the report
“(1) The inquest identified that there was insufficient staff training to deal with complex hoarder cases. ”
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 The Forward Trust; that does not assign responsibility.
PFD Monitor interpretation
Council hoarder-support guidance failing to support tenant assistance
Wider context from the report
“(3) The council "flow chart" was clearly not fit for purpose to assist staff in progressing hoarder support and assistance and was focussed on enforcement procedures rather than tenant support. The inquest was advised that the council's approach was not enforcement, but their documentation did not support 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 The Forward Trust; that does not assign responsibility.
PFD Monitor interpretation
Failure to request required fire and environmental health assessments
Wider context from the report
“(2) Other safety assessments such as a fire assessment and/or environmental health assessment were not requested despite their being a clear need. ”
Open source report
11 Aug2021
North East Kent
Concerns raised2
1. Lack of evidence of multi-agency procedures for safe discharge of patients with concurrent mental health, substance misuse, social care and physical health needs
2. Lack of evidence of multi-agency planning meetings before discharge
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

Hadley John Savory · 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

Hadley John Savory was discharged from hospital on 25 September 2019, and his presentation later declined in the community. He was found deceased at home on 13 December 2019 after toxicological evidence indicated that he had taken a lethal dose of methadone; concerns included the absence of a multi-agency planning meeting before discharge and unclear multi-agency procedures for supporting patients with concurrent health, substance misuse and social care needs.

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 The Forward Trust; that does not assign responsibility.
PFD Monitor interpretation
Lack of evidence of multi-agency procedures for safe discharge of patients with concurrent mental health, substance misuse, social care and physical health needs
Wider context from the report
“(1) There was no evidence of a multi agency planning meeting prior to Mr Savory’s discharge from Queen Elizabeth The Queen Mother Hospital on 25 September 2019. Nor was there evidence of what multi-agency procedures are in place relating to the safe discharge of patients with concurrent, mental health, substance misuse, social care and physical health needs; ”
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 The Forward Trust; that does not assign responsibility.
PFD Monitor interpretation
Lack of evidence of multi-agency planning meetings before discharge
Wider context from the report
“(1) There was no evidence of a multi agency planning meeting prior to Mr Savory’s discharge from Queen Elizabeth The Queen Mother Hospital on 25 September 2019. Nor was there evidence of what multi-agency procedures are in place relating to the safe discharge of patients with concurrent, mental health, substance misuse, social care and physical health needs; ”
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 The Forward Trust; that does not assign responsibility.
PFD Monitor interpretation
Lack of policy or guidance for additional checks of prisoners with repeated NPS use
Wider context from the report
“(1)During the inquest evidence was heard that apart from some hourly checks by prison officers during the evening of the incident on 20/10/17 (the third known instance of NPS use by the deceased) no other specific checks were made on the deceased leading up to the date of his death . This was a prisoner who had 3 known instances of NPS use within a relatively short space of time. I heard evidence that the requirement for further checks would have had to come from the Healthcare team rather than from prison officers. I was told here is no policy or guidance to cover additional checks for a prisoner in a situation such as this. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The Forward Trust; that does not assign responsibility.
PFD Monitor interpretation
Failure to communicate elevated NPS-related risk to Healthcare and prison officers
Wider context from the report
“(2)The inquest heard evidence from two Forward Trust Drug workers who although not medically qualified, considered that Mr Jones was at a ‘higher’ risk from NPS use due to using NPS with his existing congenital heart defect. I was told there was no method of communicating this to either Healthcare or prison officers to enable further periodic checks to be undertaken particularly in light of the recent incident on 20/10/17. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The Forward Trust; that does not assign responsibility.
PFD Monitor interpretation
Unavailability of relevant prisoner medical information to drug workers
Wider context from the report
“(3)The two Forward Trust Drug workers were only aware of Mr Jones existing heart condition because he disclosed this to them himself. This enabled them specifically to tailor their advice to cover the impact of Mr Jones continued NPS use on his heart. Forward Trust do not appear to have access to prisoner medical records for reasons of patient confidentiality and there does not appear to be any alternative way of ensuring they have all the information about a prisoner in order to help them with their drug use. ”
Open source report

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 raised1

Failure to document and embed the drug detoxification discharge pathway in operating procedures

Concerns raised4

Lack of clear options and forward planning after failure of an assistance plan

Insufficient staff training for dealing with complex hoarder cases

Council hoarder-support guidance failing to support tenant assistance

Failure to request required fire and environmental health assessments

Concerns raised2

Lack of evidence of multi-agency procedures for safe discharge of patients with concurrent mental health, substance misuse, social care and physical health needs

Lack of evidence of multi-agency planning meetings before discharge

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