The Forward TrustIncludes reports addressed to a minister or senior office-holder acting for this organisation.

Private and voluntary organisations · Company limited by guarantee

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First report 1 Aug 2018•Latest report 13 Nov 2023

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports
4

Naming this recipient

Published responses
25%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
5

Described in responses

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.

  1. Essex

    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

  2. West London

    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

  3. Addressed to: The Chief Executive of The Forward Trust.

    North East Kent

    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

  4. Shropshire, Telford and Wrekin

    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
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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