31 May 2024 Frazer Charlie Williams · Prevention of Future Deaths report Dorset
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Concerns raised 17 Lack of guidance on transferring prisoners under healthcare-team care between establishments View source Lack of national guidance for management and operational staff on pre-transfer prisoner handover View source Lack of consultation with receiving-prison healthcare teams about care capability View source Lack of national guidance for healthcare handover to receiving prisons View source Failure to deliver the keyworker scheme in line with national guidance View source Lack of process for recording and involving prisoners’ next of kin View source Lack of NHS and joint HMPPS guidance on identifying, managing and treating self-neglect in prisons View source Delays in transferring prisoners requiring mental health hospital admission View source Lack of a national directory of healthcare facilities and provision at individual prisons View source Lack of guidance requiring consultation with prison doctors before transferring prisoners receiving medical care View source Lack of automatic flagging of missed ACCT reviews View source Lack of ACCT quality assurance between day 7 and post-closure review View source Failure to make an immediate ambulance call when a code blue or red is raised View source Failure to invite relevant individuals such as key workers to ACCT reviews View source Lack of national specification for prison healthcare units View source Failure of the email-a-prisoner system to facilitate contact after unrecognised prisoner transfers View source Camouflaging similarity between cell-door and bedsheet colours View source See 14 more concerns
Responses linked to these concerns
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AI-generated summary
Frazer Charlie Williams · 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
Frazer Charlie Williams was found deceased on 7 March 2022 in his cell at HMP Guys Marsh, suspended by a ligature. The report identifies concerns about delays transferring prisoners requiring mental health hospital care, inadequate arrangements for managing self-neglect and healthcare handovers, shortcomings in ACCT monitoring and reviews, and other prison care and safety processes. The inquest concluded that he died by suicide in circumstances where there was inadequate assessment and monitoring of his risks of self-harm and suicide prior to his death.
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× 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 Unilink Software Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on transferring prisoners under healthcare-team care between establishments
Wider context from the report “iii. There is a lack of a national directory detailing the facilities and provision of healthcare at individual prisons across England and Wales, and associated guidance on the transfer of individuals between prison establishments when they are under the care of the healthcare teams and are not placed on medical hold . There is a lack of guidance on consultation with prison doctors where a prisoner is receiving medical care, whether that be for physical or mental health, when there is consideration by the prison to transfer the prisoner who is not placed on medical hold. Further there is a lack of consultation with the healthcare team at the proposed receiving prison to ensure they can provide the appropriate care for the person.
” 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 Unilink Software Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidance for management and operational staff on pre-transfer prisoner handover
Wider context from the report “vi. There is lack of national guidance for both senior management and operational prison staff in relation to the handover of a prisoner in advance of their transfer , not specific to, but especially those with complex needs, when transferring between prisons.
” 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 Unilink Software Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of consultation with receiving-prison healthcare teams about care capability
Wider context from the report “iii. There is a lack of a national directory detailing the facilities and provision of healthcare at individual prisons across England and Wales, and associated guidance on the transfer of individuals between prison establishments when they are under the care of the healthcare teams and are not placed on medical hold. There is a lack of guidance on consultation with prison doctors where a prisoner is receiving medical care, whether that be for physical or mental health, when there is consideration by the prison to transfer the prisoner who is not placed on medical hold. Further there is a lack of consultation with the healthcare team at the proposed receiving prison to ensure they can provide the appropriate care for the person .
” 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 Unilink Software Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidance for healthcare handover to receiving prisons
Wider context from the report “iv. There is a lack of national guidance for healthcare teams working in prisons around the handover of healthcare of a prisoner to the receiving prison when they are transferred to another 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 Unilink Software Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to deliver the keyworker scheme in line with national guidance
Wider context from the report “x. The keyworker scheme is not being delivered in line with national guidance at HMP Guys Marsh.
” 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 Unilink Software Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of process for recording and involving prisoners’ next of kin
Wider context from the report “xiii. There is a lack of process regarding the recording of a prisoner’s next of kin and involvement of them at HMP Guys Marsh.
” 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 Unilink Software Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of NHS and joint HMPPS guidance on identifying, managing and treating self-neglect in prisons
Wider context from the report “ii. There is a lack of NHS guidance, and joint guidance with HMPPS, on the identification, management, and treatment of someone with self neglect in the prison setting .
” 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 Unilink Software Limited; that does not assign responsibility.
PFD Monitor interpretation Delays in transferring prisoners requiring mental health hospital admission
Wider context from the report “i. There is inequity within the system of the treatment of a person with mental illness in the prison setting compared to an individual in the community, due to the fact that in the community a person would be placed in a hospital setting on the day they were deemed to require hospital admission, however in prison there are delays in transferring a prisoner in the same situation to hospital .
” 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 Unilink Software Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of a national directory of healthcare facilities and provision at individual prisons
Wider context from the report “iii. There is a lack of a national directory detailing the facilities and provision of healthcare at individual prisons across England and Wales , and associated guidance on the transfer of individuals between prison establishments when they are under the care of the healthcare teams and are not placed on medical hold. There is a lack of guidance on consultation with prison doctors where a prisoner is receiving medical care, whether that be for physical or mental health, when there is consideration by the prison to transfer the prisoner who is not placed on medical hold. Further there is a lack of consultation with the healthcare team at the proposed receiving prison to ensure they can provide the appropriate care for the person.
” 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 Unilink Software Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance requiring consultation with prison doctors before transferring prisoners receiving medical care
Wider context from the report “iii. There is a lack of a national directory detailing the facilities and provision of healthcare at individual prisons across England and Wales, and associated guidance on the transfer of individuals between prison establishments when they are under the care of the healthcare teams and are not placed on medical hold. There is a lack of guidance on consultation with prison doctors where a prisoner is receiving medical care , whether that be for physical or mental health, when there is consideration by the prison to transfer the prisoner who is not placed on medical hold . Further there is a lack of consultation with the healthcare team at the proposed receiving prison to ensure they can provide the appropriate care for the person.
” 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 Unilink Software Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of automatic flagging of missed ACCT reviews
Wider context from the report “viii. There is lack of automatic flagging of a missed ACCT review at HMP Guys Marsh and this could also be a national problem.
” 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 Unilink Software Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of ACCT quality assurance between day 7 and post-closure review
Wider context from the report “vii. The lack of ACCT quality assurance, or audit, between day 7 of the ACCT and the post closure review .
” 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 Unilink Software Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to make an immediate ambulance call when a code blue or red is raised
Wider context from the report “xii. PSI 03/2013 is not being followed at HMP Guys Marsh as there is no immediate call to the ambulance service when a code blue or red is raised .
” 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 Unilink Software Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to invite relevant individuals such as key workers to ACCT reviews
Wider context from the report “ix. Relevant individuals, such as key workers are not being invited to attend ACCT reviews at HMP Guys Marsh in line with ACCT 6 guidance.
” 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 Unilink Software Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of national specification for prison healthcare units
Wider context from the report “v. There is a lack of national specification in respect of prison healthcare units .
” 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 Unilink Software Limited; that does not assign responsibility.
PFD Monitor interpretation Failure of the email-a-prisoner system to facilitate contact after unrecognised prisoner transfers
Wider context from the report “xiv. The email a prisoner system is dependant on the person wanting to contact the prisoner knowing their location , so if the prisoner is transferred to another prison and the person contacting them is not aware, contact which can be a protective factor particularly in a prisoner’s mental health care, will not be facilitated.
” 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 Unilink Software Limited; that does not assign responsibility.
PFD Monitor interpretation Camouflaging similarity between cell-door and bedsheet colours
Wider context from the report “xi. The colour of the cell doors and bedsheets at HMP Guys Marsh, and possibly at other prisons nationally, being very similar can camouflage ligatures .
” Open source report
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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 Raise prisoner-movement communication issues with the Ministry of Justice and explore confidentially sharing relevant movement information to support timely message redirection.
Verbatim wording from the response “We fully recognize the importance of ensuring that such communications reach their intended recipients, particularly in situations like this, and we deeply regret any distress this may have caused. To prevent similar occurrences in the future, we will raise this issue with the Ministry of Justice and explore whether there is a possibility of confidentially sharing relevant information about prisoner movements, which could help to better manage and redirect communications in a timely manner.” Source location Response from Unilink
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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 Without access to prisoner movement information, the service could not redirect the message or notify the sender of the transfer.
Verbatim wording from the response “However, we now understand that Frazer was moved to HMP Guys March on 14th January, and it is therefore unlikely that he received this last message. As you may know, Unilink does not have access to prison rolls or prisoner movement information for security reasons. This is expected to be known by the person contacting them. In this case neither the sender nor Unilink was aware of Frazer’s transfer and hence were unable to take any action to redirect the message or notify the sender of the situation.” Source location Response from Unilink
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations