21 Feb 2020 Andrew Goldstraw · Prevention of Future Deaths report Central Hampshire
View report summary
Concerns raised 5 Failure of SystmOne search functions to extract key mental health risk information View source Failure to identify documented suicide and deliberate self-harm risk information View source SystmOne failing to facilitate retrieval of key suicide and deliberate self-harm risk information View source Failure to maintain accurate and usable summary and active-problem risk information View source Lack of effective SystmOne training and competency in suicide and deliberate self-harm risk assessment View source See 2 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
Andrew Goldstraw · 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
Andrew Goldstraw was found hanging in a cell at HM Prison, Winchester, on 14 November 2018, having taken his own life using a ligature made from torn bed linen. The report raised concerns that relevant information about his previous suicidal ideation and self-harm attempts was difficult for healthcare staff to identify in SystmOne, that the system could hinder effective risk assessment, and that staff training may have been inadequate. The inquest jury found that an ACCT should have been opened and that its absence would have more than minimally helped to prevent his death.
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 Winchester Prison; that does not assign responsibility.
PFD Monitor interpretation Failure of SystmOne search functions to extract key mental health risk information
Wider context from the report “B. SystmOne makes it difficult for a doctor or mental health nurse to ascertain the key information needed to undertake a risk assessment and to decide whether or not to open an ACCT. Too much reliance is placed on the individual prisoners presentation and how he answers a series of pre-set questions.
C. At best, SystmOne makes it difficult for a mental health nurse to ascertain the relevant information and at worst it actively misleads them. For example, a search can be made of the "journal" section but this would rely on the exact words being searched (such as "suicide" or "deliberate self-harm") and it would then be necessary to go through the various entries (in Mr Goldstraw's case spread over 111 pages) using the "Key Word Search" function. Further, the functions that would (on the face of it) serve to assist in this situation (such as the "Summary" page or "Active Problems" section) were not populated with the information relevant to an accurate assessment. It was conceded by the legal representatives acting on behalf of CNWL that the "Summary" section is "very limited in its contents" and is not routinely used by healthcare staff within the prison in order to gain an insight into a prisoner's past medical history.
D. The "Active Problems" section of SystmOne is subdivided in to a number of distinct areas and it appears to be wholly inadequate in terms of identifying key areas of concern such as the risk of suicide or deliberate self-harm. The only information contained in the "Active Problems" section of SystmOne in Mr Goldstraw's case was four years out of date. None of the relevant information was contained in "Active Problems" but a great deal of irrelevant information was there!
E. The "Communications" section of SystmOne contains a chronological record of correspondence with the hospital, GP surgery and psychiatric units. However, the "Key Word Search" facility does not function at all and short of going through all of the correspondence there is no way of identifying the key information needed to undertake an effective risk assessment. The "Communications" section in Mr Goldstraw's case amounted to 83 pages. Although the relevant information concerning Mr Goldstraw's mental health issues was contained within the "Communications" section of SystmOne there was no way of easily extracting it .
F. Accordingly, a busy, under pressure mental health nurse or doctor is very likely to struggle to find the relevant entries using SystmOne, which may explain why (in Mr Goldstraw's case) too much reliance was placed on how he presented during interview. A prisoner who chooses not to disclose his true state of mind or suicidal ideation is unlikely to come to the notice of the healthcare staff whose job it is to identify the risk that he may pose to himself because SystmOne does not facilitate 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 Winchester Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to identify documented suicide and deliberate self-harm risk information
Wider context from the report “A. The computer system used by CNWL is known as SystmOne. Healthcare staff working on Reception when Mr Goldstraw first arrived at the prison had access to his previous medical notes and history (around 240 pages in all) stored on SystmOne. The records contained numerous references to suicidal ideation and previous attempts at deliberate self-harm. Mr Goldstraw had attempted to take his own life on several previous occasions, the most recent of which was only three months prior to his arrival at the prison. However, despite a proliferation of entries making reference to his mental health history the mental health nurse who had access to SystmOne was seemingly unaware of the relevant entries . Had he been, he said he would have opened an ACCT.
” 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 Winchester Prison; that does not assign responsibility.
PFD Monitor interpretation SystmOne failing to facilitate retrieval of key suicide and deliberate self-harm risk information
Wider context from the report “B. SystmOne makes it difficult for a doctor or mental health nurse to ascertain the key information needed to undertake a risk assessment and to decide whether or not to open an ACCT . Too much reliance is placed on the individual prisoners presentation and how he answers a series of pre-set questions.
C. At best, SystmOne makes it difficult for a mental health nurse to ascertain the relevant information and at worst it actively misleads them. For example, a search can be made of the "journal" section but this would rely on the exact words being searched (such as "suicide" or "deliberate self-harm") and it would then be necessary to go through the various entries (in Mr Goldstraw's case spread over 111 pages) using the "Key Word Search" function. Further, the functions that would (on the face of it) serve to assist in this situation (such as the "Summary" page or "Active Problems" section) were not populated with the information relevant to an accurate assessment. It was conceded by the legal representatives acting on behalf of CNWL that the "Summary" section is "very limited in its contents" and is not routinely used by healthcare staff within the prison in order to gain an insight into a prisoner's past medical history.
D. The "Active Problems" section of SystmOne is subdivided in to a number of distinct areas and it appears to be wholly inadequate in terms of identifying key areas of concern such as the risk of suicide or deliberate self-harm. The only information contained in the "Active Problems" section of SystmOne in Mr Goldstraw's case was four years out of date. None of the relevant information was contained in "Active Problems" but a great deal of irrelevant information was there!
E. The "Communications" section of SystmOne contains a chronological record of correspondence with the hospital, GP surgery and psychiatric units. However, the "Key Word Search" facility does not function at all and short of going through all of the correspondence there is no way of identifying the key information needed to undertake an effective risk assessment. The "Communications" section in Mr Goldstraw's case amounted to 83 pages. Although the relevant information concerning Mr Goldstraw's mental health issues was contained within the "Communications" section of SystmOne there was no way of easily extracting it.
F. Accordingly, a busy, under pressure mental health nurse or doctor is very likely to struggle to find the relevant entries using SystmOne, which may explain why (in Mr Goldstraw's case) too much reliance was placed on how he presented during interview. A prisoner who chooses not to disclose his true state of mind or suicidal ideation is unlikely to come to the notice of the healthcare staff whose job it is to identify the risk that he may pose to himself because SystmOne does not facilitate 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 Winchester Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain accurate and usable summary and active-problem risk information
Wider context from the report “B. SystmOne makes it difficult for a doctor or mental health nurse to ascertain the key information needed to undertake a risk assessment and to decide whether or not to open an ACCT. Too much reliance is placed on the individual prisoners presentation and how he answers a series of pre-set questions.
C. At best, SystmOne makes it difficult for a mental health nurse to ascertain the relevant information and at worst it actively misleads them. For example, a search can be made of the "journal" section but this would rely on the exact words being searched (such as "suicide" or "deliberate self-harm") and it would then be necessary to go through the various entries (in Mr Goldstraw's case spread over 111 pages) using the "Key Word Search" function. Further, the functions that would (on the face of it) serve to assist in this situation (such as the "Summary" page or "Active Problems" section) were not populated with the information relevant to an accurate assessment . It was conceded by the legal representatives acting on behalf of CNWL that the "Summary" section is "very limited in its contents" and is not routinely used by healthcare staff within the prison in order to gain an insight into a prisoner's past medical history.
D. The "Active Problems" section of SystmOne is subdivided in to a number of distinct areas and it appears to be wholly inadequate in terms of identifying key areas of concern such as the risk of suicide or deliberate self-harm . The only information contained in the "Active Problems" section of SystmOne in Mr Goldstraw's case was four years out of date. None of the relevant information was contained in "Active Problems" but a great deal of irrelevant information was there!
E. The "Communications" section of SystmOne contains a chronological record of correspondence with the hospital, GP surgery and psychiatric units. However, the "Key Word Search" facility does not function at all and short of going through all of the correspondence there is no way of identifying the key information needed to undertake an effective risk assessment. The "Communications" section in Mr Goldstraw's case amounted to 83 pages. Although the relevant information concerning Mr Goldstraw's mental health issues was contained within the "Communications" section of SystmOne there was no way of easily extracting it.
F. Accordingly, a busy, under pressure mental health nurse or doctor is very likely to struggle to find the relevant entries using SystmOne, which may explain why (in Mr Goldstraw's case) too much reliance was placed on how he presented during interview. A prisoner who chooses not to disclose his true state of mind or suicidal ideation is unlikely to come to the notice of the healthcare staff whose job it is to identify the risk that he may pose to himself because SystmOne does not facilitate 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 Winchester Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of effective SystmOne training and competency in suicide and deliberate self-harm risk assessment
Wider context from the report “G. There also appeared to be a lack of training in relation to the effective use of SystmOne . In particular, it was not clear whether any steps had been taken to ensure that the staff who were working at the prison at the time of Mr Goldstraw's death had been retrained or had their competencies assessed in light of the failures identified. There is a real concern that some staff are still failing adequately to carry out assessments of a prisoners risk of suicide / deliberate self-harm.
H. The Head of Healthcare at HM Prison, Winchester has indicated that she intends to provide (in conjunction with the Prison Governor) a joint learning bulletin to all staff, stressing the importance of sharing information, most notably in reception and during the early days in custody. However, this does not address the technical shortcomings of SystmOne which present a matter of considerable concern, even if healthcare staff undertake all reasonable steps to ascertain a prisoner's previous mental health history as part of the prison induction process.
” Open source report
19 Oct 2017 Sean Patrick Plumstead · Prevention of Future Deaths report Central Hampshire
View report summary
Concerns raised 13 Failure to provide ACCT training to all relevant prison staff View source Inadequate storage of staff interview recordings View source Inadequate storage of telephone recordings View source Emergency cell bell system lacking call prioritisation and activation-time identification View source Lack of an alternative means for prisoners to request emergency assistance View source Failure to retain important documents or electronic material with specific prisoner records View source Failure to maintain adequate suicide and self-harm awareness training coverage View source Failure to train all prisoner-facing Carillion staff in self-harm and suicide prevention View source Insufficiently resourced transcription of staff interviews View source Failure to maintain training records for Carillion prisoner-facing staff View source Unclear allocation of responsibility for training prisoner-facing contractor staff View source Inadequate control of emergency cell bell misuse View source Delays in responding to emergency cell bell activations View source See 10 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
Sean Patrick Plumstead · 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
Sean Plumstead, a convicted prisoner at HM Prison Winchester, died on 18 September 2016 after being found hanging by a ligature in his cell and later having treatment withdrawn following severe brain injury. The report raised concerns about inadequate suicide and self-harm awareness training for prison and prisoner-facing staff, unclear responsibility for training Carillion staff, and delayed responses to emergency cell bells.
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 Winchester Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to provide ACCT training to all relevant prison staff
Wider context from the report “1. ACCT Training
I issued a Regulation 28 Report on 4 October 2016 in relation to a death of another prisoner at HMP Winchester ████████ concerning inter alia Assessment Care and Custody and Teamwork (ACCT) training plans and received a response from the Ministry of Justice dated 12 December 2016 in which it was stated that refresher training was taking place for 48 members of staff that month and at least monthly thereafter and that 12 new prison officers were expected to complete the Prison Officer Entry Level Training course that includes training on suicide and self-harm awareness (SASH) and ACCT process before starting work at Winchester by March 2017.
In an inquest starting on 13 March 2017 in relation to a death of another prisoner at HMP Winchester ████████ evidence was given by the prison governor that at August 2016 41% of staff had received ACCT training ; at the date the evidence was given 61% of staff had received ACCT training ; and that the aim was for 80% of staff to receive ACCT training by Autumn 2017. The Assistant Coroner issued a Regulation 28 Report on 11 April 2017 concerning inter alia ACCT training plans and received a response from the Ministry of Justice dated 21 June 2017 which stated that at the date of the letter 120 out of 162 prison officers at HMP Winchester (74%) had received ACCT training .
Evidence adduced in the inquest into the death of Mr Plumstead disclosed statistics for the provision of SASH training had been completed as follows:
• As at September 2016 77.29% of forward- facing prison service staff
• As at September 2016 64.27% of all prison service staff
• As at September 2017 72% of forward- facing prison service staff
• As at September 2017 57% of prison service staff were “in date” with such training.
The evidence was that the current aim is to achieve the 80% target by mid 2018.
It was apparent from the evidence that due to staff turnover, a lack of trainers qualified and available to provide such training and other priorities, targets for SASH training are failing to be met and if anything the ratio of prison staff with the appropriate skills is reducing rather than increasing. This means that the risk of prisoners at risk of self harm and suicide may not be recognised by staff who have had no such training with whom they come into contact.
” 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 Winchester Prison; that does not assign responsibility.
PFD Monitor interpretation Inadequate storage of staff interview recordings
Wider context from the report “(2) Winchester Prison has been unable to produce recordings of the interviews of staff and it has been stated that due to resourcing constraints written transcripts of some of the interviews were not prepared. It is uncertain whether the relevant assistant governor will be able to give live evidence of the results of her investigation and one of the officers involved is on long term absence. The systems in place for proper storage of such recordings appear to be inadequate and the administrative processes for transcription are insufficiently resourced.
” 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 Winchester Prison; that does not assign responsibility.
PFD Monitor interpretation Inadequate storage of telephone recordings
Wider context from the report “(1) Winchester Prison has been unable to produce the telephone recordings and the transcripts provided are in summary form only and so may omit potential evidence. The systems in place for proper storage of such material appear to be inadequate or non-existent.
” 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 Winchester Prison; that does not assign responsibility.
PFD Monitor interpretation Emergency cell bell system lacking call prioritisation and activation-time identification
Wider context from the report “3. Emergency Cell Bells
The emergency cell bell (ECB) in Mr Plumstead’s cell had been activated by his cellmate but the response to this took 10.5 minutes whereas the expected response time is 5 minutes. The evidence showed that there was and continues to be widespread misuse of ECB’s by prisoners particularly those on general wings, which leads to prison officers responding on occasions over an hour after the ECB has been activated. There are only limited sanctions available for enforcement of the proper use of the system by prisoners. The system allows no means of prioritising calls or identifying the time when the ECB has been pressed . Prisoners who have a genuine emergency have no alternative means of requesting assistance and therefore the risk is that there medical emergencies will not have a timely response and further deaths in such circumstances will occur. The current system is not fit for purpose and notices to prisoners are ineffective.
” 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 Winchester Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of an alternative means for prisoners to request emergency assistance
Wider context from the report “3. Emergency Cell Bells
The emergency cell bell (ECB) in Mr Plumstead’s cell had been activated by his cellmate but the response to this took 10.5 minutes whereas the expected response time is 5 minutes. The evidence showed that there was and continues to be widespread misuse of ECB’s by prisoners particularly those on general wings, which leads to prison officers responding on occasions over an hour after the ECB has been activated. There are only limited sanctions available for enforcement of the proper use of the system by prisoners. The system allows no means of prioritising calls or identifying the time when the ECB has been pressed. Prisoners who have a genuine emergency have no alternative means of requesting assistance and therefore the risk is that there medical emergencies will not have a timely response and further deaths in such circumstances will occur. The current system is not fit for purpose and notices to prisoners are ineffective.
” 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 Winchester Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to retain important documents or electronic material with specific prisoner records
Wider context from the report “(3) This is not the first death in custody at Winchester Prison where potentially important documents or electronic material has been mislaid or not found because they have not been retained with specific prisoner records . There is therefore a risk that future deaths at the prison occur when such omissions are repeated.
” 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 Winchester Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain adequate suicide and self-harm awareness training coverage
Wider context from the report “1. ACCT Training
I issued a Regulation 28 Report on 4 October 2016 in relation to a death of another prisoner at HMP Winchester ████████ concerning inter alia Assessment Care and Custody and Teamwork (ACCT) training plans and received a response from the Ministry of Justice dated 12 December 2016 in which it was stated that refresher training was taking place for 48 members of staff that month and at least monthly thereafter and that 12 new prison officers were expected to complete the Prison Officer Entry Level Training course that includes training on suicide and self-harm awareness (SASH) and ACCT process before starting work at Winchester by March 2017.
In an inquest starting on 13 March 2017 in relation to a death of another prisoner at HMP Winchester ████████ evidence was given by the prison governor that at August 2016 41% of staff had received ACCT training; at the date the evidence was given 61% of staff had received ACCT training; and that the aim was for 80% of staff to receive ACCT training by Autumn 2017. The Assistant Coroner issued a Regulation 28 Report on 11 April 2017 concerning inter alia ACCT training plans and received a response from the Ministry of Justice dated 21 June 2017 which stated that at the date of the letter 120 out of 162 prison officers at HMP Winchester (74%) had received ACCT training.
Evidence adduced in the inquest into the death of Mr Plumstead disclosed statistics for the provision of SASH training had been completed as follows:
• As at September 2016 77.29% of forward- facing prison service staff
• As at September 2016 64.27% of all prison service staff
• As at September 2017 72% of forward- facing prison service staff
• As at September 2017 57% of prison service staff were “in date” with such training.
The evidence was that the current aim is to achieve the 80% target by mid 2018.
It was apparent from the evidence that due to staff turnover, a lack of trainers qualified and available to provide such training and other priorities, targets for SASH training are failing to be met and if anything the ratio of prison staff with the appropriate skills is reducing rather than increasing . This means that the risk of prisoners at risk of self harm and suicide may not be recognised by staff who have had no such training with whom they come into contact.
” 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 Winchester Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to train all prisoner-facing Carillion staff in self-harm and suicide prevention
Wider context from the report “2. Training of All Prisoner-facing Staff
The investigation into the death of Sean Plumstead, including evidence heard during the inquest, has highlighted matters of concern relating to Carillion’s past and present operations at HMP Winchester and possibly at other establishments nationally. The evidence showed that in the 18 months before Mr Plumstead’s death in September 2016, at least two Carillion staff were employed in prisoner-facing roles at the prison (in the Clothing Exchange Store) without any training in self-harm/suicide prevention (in apparent contradiction to the national policy - the Prison Service Instruction 64/2011 in its latest version). Further, one of those staff members was expected to make entries in an (ACCT) support document without having had relevant training. As of October 2017, one of those staff members has still to be trained in self-harm/suicide prevention .
It remains unclear whether the (Carillion) Works Manager and other Carillion supervisors (at a local and national level) are aware of the issue. The prison have since assumed the responsibility for the training of all staff in prisoner-facing roles but there is, as yet, no clarity on the obligations and assumptions which Ministry of Justice and Carillion were operating at the material time (2015-2016) nor indeed what arrangements will pertain in the future. Indeed, I have also heard evidence that the prison do not hold training records for Carillion staff. There is therefore some division of responsibility between the prison and Carillion and a risk that training of staff is missed because of the absence of such records.
I consider there is a risk arising from my investigation that there was and continues to be a gap in training which Carillion is either unaware of or unconcerned with - a gap that may continue here and elsewhere. I understand that Carillion has a contractual obligation to ensure that staff provided to the prison will be appropriately trained, but I cannot identify any requirement for self-harm/suicide management training, nor any commitment by Carillion to make staff available for such training by the prison as necessary. The apparent ambiguities in the arrangement could compromise the safety of prisoners that Carillion personnel are dealing with.
I am also concerned of a risk in other prisons, where Carillion staff are directly engaging with prisoners without adequate or appropriate training in suicide and self-harm management. I invited Carillion to be an Interested Party to the inquest, a request which they declined to take up. Nevertheless, following the evidence in the inquest, the prima facie concerns have hardened. I consider Carillion has the power to take action to remedy these shortcomings and that in collaboration with the Ministry of Justice both can address these concerns and clarify responsibilities.
” 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 Winchester Prison; that does not assign responsibility.
PFD Monitor interpretation Insufficiently resourced transcription of staff interviews
Wider context from the report “(2) Winchester Prison has been unable to produce recordings of the interviews of staff and it has been stated that due to resourcing constraints written transcripts of some of the interviews were not prepared . It is uncertain whether the relevant assistant governor will be able to give live evidence of the results of her investigation and one of the officers involved is on long term absence. The systems in place for proper storage of such recordings appear to be inadequate and the administrative processes for transcription are insufficiently resourced .
” 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 Winchester Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain training records for Carillion prisoner-facing staff
Wider context from the report “2. Training of All Prisoner-facing Staff
The investigation into the death of Sean Plumstead, including evidence heard during the inquest, has highlighted matters of concern relating to Carillion’s past and present operations at HMP Winchester and possibly at other establishments nationally. The evidence showed that in the 18 months before Mr Plumstead’s death in September 2016, at least two Carillion staff were employed in prisoner-facing roles at the prison (in the Clothing Exchange Store) without any training in self-harm/suicide prevention (in apparent contradiction to the national policy - the Prison Service Instruction 64/2011 in its latest version). Further, one of those staff members was expected to make entries in an (ACCT) support document without having had relevant training. As of October 2017, one of those staff members has still to be trained in self-harm/suicide prevention.
It remains unclear whether the (Carillion) Works Manager and other Carillion supervisors (at a local and national level) are aware of the issue. The prison have since assumed the responsibility for the training of all staff in prisoner-facing roles but there is, as yet, no clarity on the obligations and assumptions which Ministry of Justice and Carillion were operating at the material time (2015-2016) nor indeed what arrangements will pertain in the future. Indeed, I have also heard evidence that the prison do not hold training records for Carillion staff . There is therefore some division of responsibility between the prison and Carillion and a risk that training of staff is missed because of the absence of such records .
I consider there is a risk arising from my investigation that there was and continues to be a gap in training which Carillion is either unaware of or unconcerned with - a gap that may continue here and elsewhere. I understand that Carillion has a contractual obligation to ensure that staff provided to the prison will be appropriately trained, but I cannot identify any requirement for self-harm/suicide management training, nor any commitment by Carillion to make staff available for such training by the prison as necessary. The apparent ambiguities in the arrangement could compromise the safety of prisoners that Carillion personnel are dealing with.
I am also concerned of a risk in other prisons, where Carillion staff are directly engaging with prisoners without adequate or appropriate training in suicide and self-harm management. I invited Carillion to be an Interested Party to the inquest, a request which they declined to take up. Nevertheless, following the evidence in the inquest, the prima facie concerns have hardened. I consider Carillion has the power to take action to remedy these shortcomings and that in collaboration with the Ministry of Justice both can address these concerns and clarify responsibilities.
” 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 Winchester Prison; that does not assign responsibility.
PFD Monitor interpretation Unclear allocation of responsibility for training prisoner-facing contractor staff
Wider context from the report “2. Training of All Prisoner-facing Staff
The investigation into the death of Sean Plumstead, including evidence heard during the inquest, has highlighted matters of concern relating to Carillion’s past and present operations at HMP Winchester and possibly at other establishments nationally. The evidence showed that in the 18 months before Mr Plumstead’s death in September 2016, at least two Carillion staff were employed in prisoner-facing roles at the prison (in the Clothing Exchange Store) without any training in self-harm/suicide prevention (in apparent contradiction to the national policy - the Prison Service Instruction 64/2011 in its latest version). Further, one of those staff members was expected to make entries in an (ACCT) support document without having had relevant training. As of October 2017, one of those staff members has still to be trained in self-harm/suicide prevention.
It remains unclear whether the (Carillion) Works Manager and other Carillion supervisors (at a local and national level) are aware of the issue. The prison have since assumed the responsibility for the training of all staff in prisoner-facing roles but there is, as yet, no clarity on the obligations and assumptions which Ministry of Justice and Carillion were operating at the material time (2015-2016) nor indeed what arrangements will pertain in the future . Indeed, I have also heard evidence that the prison do not hold training records for Carillion staff. There is therefore some division of responsibility between the prison and Carillion and a risk that training of staff is missed because of the absence of such records.
I consider there is a risk arising from my investigation that there was and continues to be a gap in training which Carillion is either unaware of or unconcerned with - a gap that may continue here and elsewhere. I understand that Carillion has a contractual obligation to ensure that staff provided to the prison will be appropriately trained, but I cannot identify any requirement for self-harm/suicide management training, nor any commitment by Carillion to make staff available for such training by the prison as necessary. The apparent ambiguities in the arrangement could compromise the safety of prisoners that Carillion personnel are dealing with.
I am also concerned of a risk in other prisons, where Carillion staff are directly engaging with prisoners without adequate or appropriate training in suicide and self-harm management. I invited Carillion to be an Interested Party to the inquest, a request which they declined to take up. Nevertheless, following the evidence in the inquest, the prima facie concerns have hardened. I consider Carillion has the power to take action to remedy these shortcomings and that in collaboration with the Ministry of Justice both can address these concerns and clarify responsibilities.
” 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 Winchester Prison; that does not assign responsibility.
PFD Monitor interpretation Inadequate control of emergency cell bell misuse
Wider context from the report “3. Emergency Cell Bells
The emergency cell bell (ECB) in Mr Plumstead’s cell had been activated by his cellmate but the response to this took 10.5 minutes whereas the expected response time is 5 minutes. The evidence showed that there was and continues to be widespread misuse of ECB’s by prisoners particularly those on general wings , which leads to prison officers responding on occasions over an hour after the ECB has been activated. There are only limited sanctions available for enforcement of the proper use of the system by prisoners . The system allows no means of prioritising calls or identifying the time when the ECB has been pressed. Prisoners who have a genuine emergency have no alternative means of requesting assistance and therefore the risk is that there medical emergencies will not have a timely response and further deaths in such circumstances will occur. The current system is not fit for purpose and notices to prisoners are ineffective.
” 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 Winchester Prison; that does not assign responsibility.
PFD Monitor interpretation Delays in responding to emergency cell bell activations
Wider context from the report “3. Emergency Cell Bells
The emergency cell bell (ECB) in Mr Plumstead’s cell had been activated by his cellmate but the response to this took 10.5 minutes whereas the expected response time is 5 minutes . The evidence showed that there was and continues to be widespread misuse of ECB’s by prisoners particularly those on general wings, which leads to prison officers responding on occasions over an hour after the ECB has been activated . There are only limited sanctions available for enforcement of the proper use of the system by prisoners. The system allows no means of prioritising calls or identifying the time when the ECB has been pressed. Prisoners who have a genuine emergency have no alternative means of requesting assistance and therefore the risk is that there medical emergencies will not have a timely response and further deaths in such circumstances will occur. The current system is not fit for purpose and notices to prisoners are ineffective.
” Open source report
21 Jun 2017 Michael Folley · Prevention of Future Deaths report Central Hampshire
View report summary
Concerns raised 13 Failure to complete SASH forms for risk information emerging outside current court detention View source Failure to ensure clarity about information available during prison reception View source Failure to ensure Detention Officer PER training is completed View source Failure to complete SASH forms for relevant recent self-harm or suicide risk View source Failure to ensure receipt and training for important medical and risk information at prison reception View source Cell safety features permitting door wedging and ligature use View source Radio connection delays affecting emergency information relay View source Failure to ensure secure handover of PER documentation View source Failure to provide PER staff with relevant previous self-harm and suicide risk information View source Failure of court custody staff to contribute relevant risk information to the PER View source Incomplete provision of anti-ligature protection on cell doors View source Failure to record checks of PER completion and quality View source Failure of regular maintenance checks to identify defective anti-barricade doors View source See 10 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
Michael Folley · 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
Michael Folley was remanded to HMP Winchester on 15 September 2017 and was found the following day suspended from a ligature made from torn bed sheets after barricading his cell door with mirrors and furniture. He was taken to hospital and died on 18 September 2017 after intensive care treatment. The principal concerns included the transfer and use of information about self-harm risk between police, court and prison; staff training; cell safety and maintenance; systems for checking barricaded cell doors; and the effectiveness of prison radios in relaying emergency calls.
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 Winchester Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to complete SASH forms for risk information emerging outside current court detention
Wider context from the report “I was also left with a concern that GEOAmey staff would only complete a SASH form if the current risk was identified during Mr Folley’s detention at Portsmouth magistrates’ court and not if anything came to the attention of the court detention officer to indicate there was a risk of self-harm or suicide within the last month before arrest .
” 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 Winchester Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure clarity about information available during prison reception
Wider context from the report “During the inquest, it became apparent that despite extensive questioning of police/custody staff, GEOAmey staff, prison officers and healthcare professionals, it would not be possible to establish with any degree of certainty exactly what information was available during the induction process once Mr Folley arrived at prison.
I heard from prison officers and a senior nurse involved in the reception process but there was no clarity regarding exactly what information was available to them namely, the PER itself, the HDLS reports or information that had clearly been faxed to the prison by court staff such as the warrants setting out the grounds for the remand.
” 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 Winchester Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure Detention Officer PER training is completed
Wider context from the report “c) Detention Officer PER training may not have been completed if a DO had many years of experience in the police force which would give what he referred to as “grandfather rights” .
” 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 Winchester Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to complete SASH forms for relevant recent self-harm or suicide risk
Wider context from the report “h) The suicide/self harm warning alert (SASH) at page 9 of the PER was meant to be completed if there was a risk of self-harm or suicide since arrest or within the last month . In other words, it was felt the relevant period to be considered was not just the current period of detention but also anything relevant within a month before arrest. In this case the SASH form was never completed .
” 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 Winchester Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure receipt and training for important medical and risk information at prison reception
Wider context from the report “The nurse confirmed that at the time of Mr Folley’s reception checks he did not see the PER or HLDS reports but told me that he now does. In addition, he could not recall any specific training and the system for receipt of important medical information sounded haphazard as hardcopy documents were simply left on a desk .
” 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 Winchester Prison; that does not assign responsibility.
PFD Monitor interpretation Cell safety features permitting door wedging and ligature use
Wider context from the report “I heard evidence that prisoners are issued with plastic mirrors that are frequently used as wedges in cell doors . This means officers are vigilant to ensure prisoners only have one mirror each and if there are more in a cell than necessary they will be removed. It was suggested that a thicker mirror could be issued or a mirror/reflective panel could be inserted into the wall. This was an ongoing process of replacement in the prison.
Window design was also being considered and I was informed a trial had begun prison to roll out a new type of window but that this could take up to 2 years to complete .
” 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 Winchester Prison; that does not assign responsibility.
PFD Monitor interpretation Radio connection delays affecting emergency information relay
Wider context from the report “There was conflicting evidence during inquest about the effectiveness of when the Code Blue call was made and whether this resulted in any delay in the information being passed to the ambulance service. On balance of probabilities, the problem seemed to come from the fact that the custody manager did give the correct callsign but because there is a two second delay when pressing the radio button this may not have been picked up immediately in the control room . This is of significant concern both in respect of the safety prison officers but also the need to obtain medical help for prisoners and suggests the need to update the radio system
” 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 Winchester Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure secure handover of PER documentation
Wider context from the report “e) The responsibility for the completion and quality of the PER rests with the releasing Custody Sergeant. When checking the detention log in the custody record in this case, there was no specific entry. This may not necessarily mean it was not checked by the custody sergeant but if it was then that action should be recorded.
f) It is the custody sergeant’s responsibility to ensure the safe transportation of a PER and associated documents by placing them in an envelope or other secure means that all documentation is safely handed over to the court custody officers .
” 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 Winchester Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to provide PER staff with relevant previous self-harm and suicide risk information
Wider context from the report “b) Mr Folley was assessed as NCTS (no current thoughts of self-harm or suicide) and thus placed on the lowest observation rate of 60 minutes. However, access to previous data held on police (both internal and external) and other agency systems was not available to officers completing the PER and thus they could rely on current observations only . Despite this, it was essential to consider the risk of self-harm or suicide demonstrated and recorded over the previous months (July – September) not simply since detention on this occasion.
” 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 Winchester Prison; that does not assign responsibility.
PFD Monitor interpretation Failure of court custody staff to contribute relevant risk information to the PER
Wider context from the report “I am concerned that the impression created was that GEOAmey staff do not actively engage in and contribute to the contents of the PER to highlight any information relevant to risk assessment irrespective of what source it comes from.
In addition, there was apparently no log of ████████ call to the court cells. The electronic PER had been checked and nothing was logged. There is no reason to believe ████████ call was not made and it is of concern that there was no apparent system for logging such a call let alone action in the contents of her request .
” 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 Winchester Prison; that does not assign responsibility.
PFD Monitor interpretation Incomplete provision of anti-ligature protection on cell doors
Wider context from the report “I also heard that steps had been taken to fit anti-ligature strips in some but not all cell doors .
All of these suggestions seemed eminently sensible yet the pace of these changes does need to be considered .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Winchester Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to record checks of PER completion and quality
Wider context from the report “e) The responsibility for the completion and quality of the PER rests with the releasing Custody Sergeant. When checking the detention log in the custody record in this case, there was no specific entry . This may not necessarily mean it was not checked by the custody sergeant but if it was then that action should be recorded .
f) It is the custody sergeant’s responsibility to ensure the safe transportation of a PER and associated documents by placing them in an envelope or other secure means that all documentation is safely handed over to the court custody officers.
” 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 Winchester Prison; that does not assign responsibility.
PFD Monitor interpretation Failure of regular maintenance checks to identify defective anti-barricade doors
Wider context from the report “I heard evidence that every effort was made to gain quick access into Mr Folley self once it became apparent that he had barricaded the door. This was significantly hindered by painting the screws on the anti-barricade plate but significantly, by the fact that even when the plate was removed the bar would not open outwards towards this landing due to a brick hanging down in the door frame. Whilst it has to be accepted that Winchester prison is not a modern prison nevertheless this should have been picked up during regular maintenance checks . I was shown some records this tended to imply that either checks had not been carried out on a regular basis or the checks themselves were not adequate . Either way this is of concern.
” Open source report
16 May 2016 Sheldon Woodford · Prevention of Future Deaths report Central Hampshire
View report summary
Concerns raised 2 Failure to make the SASH document identifiable to all relevant staff during reception View source Lack of training of officers in ACCT processes View source
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
Sheldon Woodford · 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
Sheldon Woodford was found hanging in his prison cell on 9 March 2015 and subsequently died in hospital on 12 March 2015 after sustaining a significant hypoxic brain injury. The report identified concerns about the identification of the SASH document during reception, ACCT process training, staffing levels, and the unstructured application of the ACCT process, including inadequate integration between prison staff and healthcare.
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 Winchester Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to make the SASH document identifiable to all relevant staff during reception
Wider context from the report “(1)That in the reception process the SASH document is not identifiable to all relevant staff .
(2)Training of Officers in the ACCT processes.
” 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 Winchester Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of training of officers in ACCT processes
Wider context from the report “(1)That in the reception process the SASH document is not identifiable to all relevant staff.
(2)Training of Officers in the ACCT processes .
” Open source report
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations