Recipient

Woodhill Prison

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First report 26 May 2016•Latest report 24 Mar 2026

Recipient record

Reports, concerns and published responses

Justice · Prison or young offender institution. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports
7

Naming this recipient

Published responses
14%

Found for named reports

Concerns addressed
6

Across all linked responses

Stated actions
12

Described in responses

Reports over time

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.

14%published responses found
12stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

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

  1. Milton Keynes

    AI-generated summary

    Ronald William MEIKLE · 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

    Ronald William Meikle was found unresponsive in his single-occupancy cell at HMP Woodhill on 30 April 2024 and was pronounced dead at 09:43. The report identified concerns about illicit substances, inconsistent responses to suspected intoxication, fragmented information-sharing, inadequate welfare observations, management of self-isolation and vulnerability, absence of ACCT proceedings, mental-health input, emergency response, staffing, and recurring systemic problems at the prison.

    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 Woodhill Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Weak supervision and staff-prisoner engagement

    Wider context from the report

    “Concern 10: Staffing, supervision and regime limitations The evidence before the court, including wider inspection material, raised concern that staffing pressures, weak supervision, poor staff-prisoner engagement, restricted regimes, and inadequate welfare observations may materially increase the risk of undetected drug use, delayed discovery of collapsed prisoners and failure to identify vulnerable men in need of intervention. ”
    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 Woodhill Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to maintain a clear and current drug under the influence policy

    Wider context from the report

    “Concern 2: Failure consistently to identify, record and respond to prisoners under the influence The evidence showed concerns about the consistency with which prisoners suspected or found to be under the influence of illicit substances were identified, clinically assessed, monitored, referred to substance misuse services, and managed under prison and healthcare processes. There was evidence that episodes of apparent intoxication were not always met with a consistent healthcare response or documented follow-up. The head of service had an understanding of the drug under the influence policy that was starkly different to the written document. There had been multiple updates of the drug policy which were difficult to identify as to when the policy was updated / revised. I am concerned that prisoners at acute risk of overdose or deterioration may therefore not receive timely intervention. ”
    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 Woodhill Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Delays or insufficiency in psychiatric assessment and proactive mental health review

    Wider context from the report

    “Concern 8: Delay or insufficiency in mental health and psychiatric input The evidence raised concern that prisoners with known vulnerabilities, substance misuse history and symptoms of deteriorating mental health may not always receive timely psychiatric assessment or sufficiently proactive mental health review. Delays in specialist assessment can increase the risk of unmanaged distress, relapse to substance use and death. ”
    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 Woodhill Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to recognise suspected synthetic cannabinoid intoxication promptly during collapse response

    Wider context from the report

    “Concern 9: Emergency response to suspected synthetic cannabinoid collapse The evidence raised concern about whether staff responding to collapse were adequately trained and equipped to consider synthetic cannabinoid intoxication promptly as a possible cause. Synthetic cannabinoid use can cause rapid deterioration and death. If staff do not recognise that possibility, there is a risk of delay in appropriate emergency action, clinical escalation and treatment. ”
    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 Woodhill Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Insufficient staffing capacity

    Wider context from the report

    “Concern 10: Staffing, supervision and regime limitations The evidence before the court, including wider inspection material, raised concern that staffing pressures, weak supervision, poor staff-prisoner engagement, restricted regimes, and inadequate welfare observations may materially increase the risk of undetected drug use, delayed discovery of collapsed prisoners and failure to identify vulnerable men in need of intervention. ”
    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 Woodhill Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Restricted prison regimes

    Wider context from the report

    “Concern 10: Staffing, supervision and regime limitations The evidence before the court, including wider inspection material, raised concern that staffing pressures, weak supervision, poor staff-prisoner engagement, restricted regimes, and inadequate welfare observations may materially increase the risk of undetected drug use, delayed discovery of collapsed prisoners and failure to identify vulnerable men in need of intervention. ”
    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 Woodhill Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Insufficiently robust identification and management of prisoners remaining behind their door because of vulnerability

    Wider context from the report

    “Concern 5: Management of self-isolation, debt, fear and vulnerability The evidence suggested that Mr Meikle had vulnerabilities connected to self-isolation, debt, fear of other prisoners, possible coercion or bullying, mental ill-health, and substance misuse. I am concerned that the systems for identifying and managing prisoners who remain behind their door because of debt, fear, vulnerability or drug-related pressures were not sufficiently robust, coordinated or escalated. ”
    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 Woodhill Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Inadequate welfare observations

    Wider context from the report

    “Concern 10: Staffing, supervision and regime limitations The evidence before the court, including wider inspection material, raised concern that staffing pressures, weak supervision, poor staff-prisoner engagement, restricted regimes, and inadequate welfare observations may materially increase the risk of undetected drug use, delayed discovery of collapsed prisoners and failure to identify vulnerable men in need of intervention. ”
    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 Woodhill Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Inconsistent identification, assessment, monitoring and response to prisoners under the influence of illicit substances

    Wider context from the report

    “Concern 2: Failure consistently to identify, record and respond to prisoners under the influence The evidence showed concerns about the consistency with which prisoners suspected or found to be under the influence of illicit substances were identified, clinically assessed, monitored, referred to substance misuse services, and managed under prison and healthcare processes. There was evidence that episodes of apparent intoxication were not always met with a consistent healthcare response or documented follow-up. The head of service had an understanding of the drug under the influence policy that was starkly different to the written document. There had been multiple updates of the drug policy which were difficult to identify as to when the policy was updated / revised. I am concerned that prisoners at acute risk of overdose or deterioration may therefore not receive timely intervention. ”
    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 Woodhill Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to escalate prisoners with cumulative vulnerability indicators into safer custody procedures

    Wider context from the report

    “Concern 6: Absence of ACCT despite identifiable indicators of vulnerability The concern is not that ACCT documentation disclosed a missed risk factor, but that the available materials show Mr Meikle was not subject to ACCT proceedings, despite evidence shortly before death of self-isolation, debt-related vulnerability, known substance misuse and reduced engagement. This occurred in an establishment where HM Inspectorate of Prisons had already identified weaknesses in ACCT management and welfare checking during an unannounced inspection in 2023 and had issued an Urgent Notification which included reference to "frailties in ACCT case management". I later became aware of a second Urgent Notification issued in March 2026, shortly after completion of Mr Meikle's inquest that once again identified "frailties in ACCT case management". I am concerned that prisoners presenting with cumulative indicators of vulnerability may not be escalated into safer custody procedures when required, thereby increasing the risk that deteriorating welfare is not recognised or managed. ”
    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 Woodhill Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Availability of illicit substances in custody

    Wider context from the report

    “Concern 1: Availability of illicit substances in custody The evidence indicated that illicit drugs ████████ were readily available within HMP Woodhill. Material before the court showed this was not an isolated issue but part of a wider and continuing prison safety problem at HMP Woodhill and likely other prisons. The availability of synthetic cannabinoids in custody creates a foreseeable risk of sudden collapse, respiratory compromise, cardiac arrest, psychosis, violence, self-harm and death. ”
    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 Woodhill Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to reliably consolidate and share relevant prisoner risk information

    Wider context from the report

    “Concern 3: Fragmented information-sharing and record keeping The evidence demonstrated that relevant risk information was spread across multiple recording systems and was not always shared effectively between operational staff and clinical teams. This included information relevant to substance misuse, mental health, debt, bullying or coercion, self-isolation, intelligence about threats, recent presentation under the influence. Where critical safety information is held in separate systems and not reliably brought together, there is a foreseeable risk that warning signs will be missed and protective action delayed with obvious risk of harm or death. ”
    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 Woodhill Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to maintain unobstructed observation panels for effective visual welfare checks

    Wider context from the report

    “Concern 4: Blocked observation panels and inadequate visual welfare checks The evidence raised serious concern that blocked observation panels were not consistently challenged or cleared, and that visual welfare checks were therefore not always effective. The jury heard evidence that officers deliberately avoided opening blocked hatches to escape abuse from the prisoners then or later. In a prison environment where prisoners may be intoxicated, unconscious, self-harming, assaulted, or otherwise incapacitated behind a locked door, failure to maintain an unobstructed observation panel creates an obvious risk of late discovery and preventable death. ”
    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 Woodhill Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Delays in supplying material information relevant to death investigations and future-death prevention

    Wider context from the report

    “Concern 12: Failure of state agencies to supply all information in a timely fashion. In this Inquest I was presented with material information at the eleventh hour. Aside from being discourteous to the family and the Court such tardy provision has potential to frustrate a full investigation into the death and allow elements of care which may impact on future deaths to pass unnoticed. ”
    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 Woodhill Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to implement sufficient and sustained remedial action on identified prison safety concerns

    Wider context from the report

    “Concern 11: Repeated systemic concerns at HMP Woodhill Material before the court from oversight and inspection bodies demonstrated that concerns about drugs, safety, violence, self-isolation, observation panel compliance, ACCT weaknesses and welfare monitoring at HMP Woodhill had been identified over time. I am concerned that repeated identification of these issues has not resulted in sufficient or sustained remedial action, creating an ongoing risk of further deaths. ”
    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 Woodhill Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to recognise IPP status as a material vulnerability requiring structured support and review

    Wider context from the report

    “Concern 7: Particular vulnerability of prisoners serving IPP (Imprisonment for Public Protection) sentences The evidence showed that prisoners serving IPP sentences may experience hopelessness, chronic frustration, deterioration in mental health and increased vulnerability to substance misuse and self-neglect. I am concerned that Mr Meikle's IPP status was not sufficiently recognised as a material risk factor requiring structured support, regular review and coordinated care. ”
    Open source report

  2. Buckinghamshire

    AI-generated summary

    George EMMETT · 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

    George Emmett died after taking synthetic cannabinoid in G-Wing at HMP Aylesbury on 25 May 2023. The report raises a continuing concern that emergency responses involving prisoners may be compromised if staff do not follow the HMPPS Medical Emergency Response Codes policy, including promptly summoning an ambulance and calling a Code Blue.

    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 Woodhill Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of operational staff to follow local medical emergency response protocols

    Wider context from the report

    “Evidence at the inquest demonstrated a Code Blue should be called over the radio from the cell location where a situation such as that in which George was found has arisen. The evidence of OSG ████████ did not appear to demonstrate familiarity with the processes set out in this policy at the time of George's death, nor any greater familiarity during evidence given, some two years after George's death. It is understood OSG ████████ holds a similar role at HMP Woodhill. There is a continuing concern that optimum reaction to an emergency situation involving the health of a prisoner may be compromised if OSG ████████ were to react in a manner which was not in accordance with any local protocols reflective of the HMPPS Medical Emergency Response Codes policy. The circumstances anticipated by this policy include situations where a prisoner's death may be prevented with appropriate application of an emergency response. ”
    Open source report

  3. Milton Keynes

    AI-generated summary

    Darren Barry 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

    Darren Williams was found hanging from a bed frame in his cell at HMP Woodhill on 4 January, and the inquest jury concluded that he took his own life. The report identifies failures in ACCT procedures, action planning, information sharing and the provision of support. Concerns included ACCT reviews taking place without Healthcare attendance and relevant information from previous ACCTs not being considered when new ACCTs were opened.

    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 Woodhill Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to take relevant information from previous ACCTs into consideration when opening a new ACCT

    Wider context from the report

    “I have two concerns; firstly, it became apparent during the course of the evidence that ACCT reviews were being conducted on many occasions without someone from Healthcare being in attendance. Secondly in this particular case there were four separate ACCT’s and it was apparent that not all relevant information available from previous ACCT’s was taken into consideration when a new ACCT was opened. ”
    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 Woodhill Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of Healthcare attendance at ACCT reviews

    Wider context from the report

    “I have two concerns; firstly, it became apparent during the course of the evidence that ACCT reviews were being conducted on many occasions without someone from Healthcare being in attendance. Secondly in this particular case there were four separate ACCT’s and it was apparent that not all relevant information available from previous ACCT’s was taken into consideration when a new ACCT was opened. ”
    Open source report

  4. Milton Keynes

    AI-generated summary

    William VICKERS · 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

    William Vickers was found collapsed in his cell at HMP Woodhill on 19 July 2018, was resuscitated and taken to hospital after suffering hypoxic brain damage, and died there on 26 July 2018. The report raised concern about delays in prison staff gaining access and, in particular, the 11-minute delay escorting the ambulance through five sets of gates to reach him.

    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 Woodhill Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of ambulance crew access to the SCAS radio system

    Wider context from the report

    “Firstly, I was told during the course of the evidence that the ambulance crew who attended the prison in response to the emergency call, did not have access to the radio system of SCAS. The ambulance which attended is operated by Jigsaw Medical Services which is denied access to the system. I believe this policy should be reviewed urgently and consideration given to ensure that all ambulance crews have access to 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 Woodhill Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to ensure unobstructed ambulance access through all security gates

    Wider context from the report

    “During the course of the evidence I was concerned that once the ambulance was admitted through the main gate it then took 11 minutes for the ambulance to be escorted through 5 sets of gates to the incident. Consideration must be given to a robust system of ensuring that all gates are opened and manned by security staff so that the ambulance is not in any way hindered in getting to their patient. The present system in my view puts prisoners’ lives at risk. ”
    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 Woodhill Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to include a fully qualified paramedic in the first response to prison emergencies

    Wider context from the report

    “Secondly I am concerned that the first response did not include a “paramedic”. I believe that consideration should be given to a review to ensure that the first responder to an emergency at the prison should always include a fully qualified paramedic. ”
    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 Woodhill Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of staff confidence in using AEDs within the prison

    Wider context from the report

    “During the course of the evidence I was concerned that not all staff within the prison, including those within healthcare, were confident in using the AED (Automatic External Defibrillator) and believe that the training of all staff should be reviewed so all are both familiar and confident in its use. ”
    Open source report

  5. Milton Keynes

    AI-generated summary

    Daniel Gary Dunkley · 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

    Daniel Gary Dunkley was found hanging in his cell at H.M.P. Woodhill on 29 July 2016 and subsequently died in hospital on 2 August 2016. Three referrals for a full mental health assessment had been made before his death, but none took place; the report identified concerns about the assessment process and the failure to notify the relevant unit or Mr Dunkley about an assessment scheduled for the morning he was found.

    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 Woodhill Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to conduct referred full mental health assessments

    Wider context from the report

    “During the course of the evidence it became clear that prior to Mr Dunkley's death three referrals were made for him to undergo a full mental health assessment. None of the assessments took place prior to his death. The assessment due on the morning that he was found hanging in his cell was never notified to House Unit 2 or indeed to Mr Dunkley. Such assessments are vital to keep those suffering from psychiatric problems to be kept safe and an urgent review of the whole process is necessary. ”
    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 Woodhill Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to notify relevant staff and patients of scheduled mental health assessments

    Wider context from the report

    “During the course of the evidence it became clear that prior to Mr Dunkley's death three referrals were made for him to undergo a full mental health assessment. None of the assessments took place prior to his death. The assessment due on the morning that he was found hanging in his cell was never notified to House Unit 2 or indeed to Mr Dunkley. Such assessments are vital to keep those suffering from psychiatric problems to be kept safe and an urgent review of the whole process is necessary. ”
    Open source report

  6. Buckinghamshire

    AI-generated summary

    JACK OLIVER PORTLAND · 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

    Jack Oliver Portland was a prisoner who was diagnosed with substance-induced psychosis and later detained under the Mental Health Act. He died on 27 December 2015 at Wycombe Hospital while on unescorted leave from the Whiteleaf Centre; the medical cause of death was morphine and ethanol toxicity. Concerns included the management and communication of ACCT documents, family communication, discharge planning for a vulnerable and homeless prisoner, and the coordination of coronial disclosure.

    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 Woodhill Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of communication between healthcare staff and prison staff about healthcare records

    Wider context from the report

    “(1) It was identified that some elements of the management of the ACCT documents during Mr Portland’s detention at HMP Woodhill, in particular insufficient detail of prisoner issues in the caremap and in post-closure review, late completion of a post-closure review, communication between healthcare staff (who have access to the healthcare SystemOne records) and prison staff (who do not) were of concern and remain so, notwithstanding general evidence indicating that the prison have been implementing ACCT quality review measures, automatic referral for a mental health assessment on opening of an ACCT and a NOMS-led taskforce. ”
    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 Woodhill Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to complete timely and accurate Root Cause Analysis reports

    Wider context from the report

    “(5) The actions taken in relation to the preparation of two Root Cause Analysis reports were of concern in that the first RCA was founded on inaccurate information and the second RCA still contained inaccuracies and was not completed until some 11 months after the fatal event. The ability to react quickly to issues raised and to implement new policies and working practices may have been compromised by the delays and lack of robustness of the reports. The recommendations of the second RCA indicate reviews to be conducted by February/March 2017 but do not appear to address more urgent practical action or possible staff training 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 Woodhill Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to establish and communicate a clear AWOL and leave authorisation procedure

    Wider context from the report

    “(3) The implementation of the AWOL procedure and checklist, including the application of 10-minute buffer time immediately at the end of scheduled leave was not clearly understood by witnesses in person and there appeared to be no proper overarching leave policy including proper recording of who assessed a patient prior to leave and who authorised a particular leave. There was no proper contemporaneous record of all the steps actually taken in connection of Mr Portland’s AWOL. ”
    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 Woodhill Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to disclose contemporaneous RCA information

    Wider context from the report

    “(6) Disclosure, initially to the Coroner, of contemporaneous interviews and information gathered during the early stages of the first RCA may have assisted in preventing subsequent delays and progressing the inquest process, enabling learning from any identified concerns to have been addressed at an earlier stage. In any event such notes and related documents did not form part of the disclosure. ”
    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 Woodhill Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Inadequate communication with families during the ACCT process

    Wider context from the report

    “(2) The standard letter notifying a family of the opening of an ACCT was non-specific and dependent upon prisoner consent, yet it was identified that the engagement of families in the ACCT process was important, particularly in the context of risk assessment. It appeared that the same letter is still in use, directing families to telephone extensions for prison staff and healthcare or a 24-hour help line. The family evidence was that communication with the prison in response to a letter received during the first ACCT was of significant concern and that they were not notified of the second ACCT. There was evidence suggesting that the helpline is now attended regularly and messages dealt with but the overall communication paths appear to remain the same. ”
    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 Woodhill Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to obtain and update patients’ risk history and assessment

    Wider context from the report

    “(4) Whilst evidence from Whiteleaf indicated they were very used to receiving patients with little or no history and assessing them, the evidence in this case indicated that they had taken across the risk assessment from the Dene Hospital on transfer, that this had not been updated during Mr Portland’s time at Whiteleaf and that Whiteleaf did not appear to have taken any steps to identify and procure any earlier history in relation to Mr Portland’s time at HMP Woodhill. It was acknowledged in evidence that knowledge of risk of self-harm recorded in the HMP Woodhill ACCT documents would have been helpful. ”
    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 Woodhill Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Insufficient detail in ACCT caremaps and post-closure reviews

    Wider context from the report

    “(1) It was identified that some elements of the management of the ACCT documents during Mr Portland’s detention at HMP Woodhill, in particular insufficient detail of prisoner issues in the caremap and in post-closure review, late completion of a post-closure review, communication between healthcare staff (who have access to the healthcare SystemOne records) and prison staff (who do not) were of concern and remain so, notwithstanding general evidence indicating that the prison have been implementing ACCT quality review measures, automatic referral for a mental health assessment on opening of an ACCT and a NOMS-led taskforce. ”
    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 Woodhill Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to complete leave observation charts contemporaneously and consistently

    Wider context from the report

    “(3) The manually-completed observation charts, forming the third element of an effective leave management process, were acknowledged to be filled out sometimes retrospectively, sometimes prospectively, sometimes by reference to the whiteboard (and evidence suggested amended later) rather than always being completed in the ward round. There was scope for human error and discrepancies between the various records of leave. ”
    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 Woodhill Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to maintain an accurate and reliable leave tracking system

    Wider context from the report

    “(2) A specific request for leave from the patient would be actioned by a nursing-level assessment, authorisation of the specific leave by the nurse in charge and implementation of the leave by a staff member. A Record of Leave of Absence would be completed and signed by the patient and the staff member and that staff member would usually then write up that patient’s name and the times out and due back on a whiteboard in the office. Evidence from witnesses confirmed that there was no particular order to the whiteboard. In the case of Mr Portland, his final leave had not been written on the whiteboard correctly and his absence was not identified until well over an hour after he was due back. The evidence indicated that the whiteboard is still used in the same way, notwithstanding that it was acknowledged that there was scope for human error and that addressing the issue was a matter of urgency. ”
    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 Woodhill Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to implement changes with clear timescales and adequate coverage of identified concerns

    Wider context from the report

    “(7) Whilst there were indications that there were changes being implemented, there was no clear indication of timescales nor did they address the particular concerns identified during this investigation. ”
    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 Woodhill Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Delays in identifying relevant witnesses and providing witness statements for coronial investigations

    Wider context from the report

    “(4) In relation to the coronial investigation and the inquest itself, there were significant concerns surrounding the co-ordination of disclosure by HMP Woodhill, initially by volume disclosure direct to the coroner, and subsequently in a piecemeal, partial fashion via Government Legal Department. Emails in which prison staff and/or healthcare staff were participants and which were very relevant to issues raised in the inquest became identifiable only through production records and there was a concern that relevant communications should have formed part of the specific prisoner records and been part of the HMP Woodhill disclosure. Whilst significant urgent work was undertaken by Government Legal Department during the inquest itself to assist the court with additional and correct documentation, these concerns, together with late identification of relevant witnesses and provision of witness statements caused delays to the coronial investigation which may have also have delayed the overall learning process and compromised the ability of HMP Woodhill to implement change in a manner specific to the issues and concerns identified, rather than in the broader terms described during the inquest. ”
    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 Woodhill Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to coordinate complete and appropriately recorded disclosure for coronial investigations

    Wider context from the report

    “(4) In relation to the coronial investigation and the inquest itself, there were significant concerns surrounding the co-ordination of disclosure by HMP Woodhill, initially by volume disclosure direct to the coroner, and subsequently in a piecemeal, partial fashion via Government Legal Department. Emails in which prison staff and/or healthcare staff were participants and which were very relevant to issues raised in the inquest became identifiable only through production records and there was a concern that relevant communications should have formed part of the specific prisoner records and been part of the HMP Woodhill disclosure. Whilst significant urgent work was undertaken by Government Legal Department during the inquest itself to assist the court with additional and correct documentation, these concerns, together with late identification of relevant witnesses and provision of witness statements caused delays to the coronial investigation which may have also have delayed the overall learning process and compromised the ability of HMP Woodhill to implement change in a manner specific to the issues and concerns identified, rather than in the broader terms described during the inquest. ”
    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 Woodhill Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to maintain contemporaneous records of AWOL actions

    Wider context from the report

    “(3) The implementation of the AWOL procedure and checklist, including the application of 10-minute buffer time immediately at the end of scheduled leave was not clearly understood by witnesses in person and there appeared to be no proper overarching leave policy including proper recording of who assessed a patient prior to leave and who authorised a particular leave. There was no proper contemporaneous record of all the steps actually taken in connection of Mr Portland’s AWOL. ”
    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 Woodhill Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Delays in completing ACCT post-closure reviews

    Wider context from the report

    “(1) It was identified that some elements of the management of the ACCT documents during Mr Portland’s detention at HMP Woodhill, in particular insufficient detail of prisoner issues in the caremap and in post-closure review, late completion of a post-closure review, communication between healthcare staff (who have access to the healthcare SystemOne records) and prison staff (who do not) were of concern and remain so, notwithstanding general evidence indicating that the prison have been implementing ACCT quality review measures, automatic referral for a mental health assessment on opening of an ACCT and a NOMS-led taskforce. ”
    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 Woodhill Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to provide S17 leave records to required recipients

    Wider context from the report

    “(1) The practical implementation of S17 leave involved, firstly, the grant of leave by the consultant psychiatrist and it was mandatory to provide copies of those Records of Grant not only to the patient, but also to the family of a patient along with the Inpatient clinical team and the MHA administrator. The Care Co-ordinator and GP were also optional recipients. No copies of any of Mr Portland’s S17 Records of Grant of Leave appeared to have been provided to anyone other than the patient. The family were unaware of changes to leave and were unable to participate in the leave process or assist Whiteleaf with regard to any heightened risks. ”
    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 Woodhill Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to adequately assess and manage discharge needs of vulnerable prisoners

    Wider context from the report

    “(3) There were concerns about the assessment and management of Mr Portland’s discharge needs from admission, particularly with regard to post-release accommodation and positive identification of registration with a GP, given that Mr Portland was homeless and that aftercare ultimately would be dependent upon GP engagement. It was accepted that it is mandatory for prisoner discharges to be undertaken in accordance with the relevant Prison Service Instruction and Early Days and Discharge Specification with all that those encompass. There remains a concern regarding the discharge of prisoners presenting with issues such as those of Mr Portland – a risk of self-harm, substance addiction, homelessness, resolving substance-induced psychosis, vulnerability. ”
    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Complete Safer Prisons post-closure checks using a quality-assurance template to verify timescales, caremap actions and closure-questionnaire invitations.

    Verbatim wording from the response

    “After closure of an ACCT a post closure check will be completed by the Safer Prisons team. A quality assurance template is used to check that the post closure process has been completed within timescales, that caremap actions were considered and completed prior to closure and that the prisoner has been invited to complete the closure questionnaire. As with all quality assurance checks any feedback required will be provided to the Case Manager involved.”

    Source location

    2017-0049-Response-by-NOMS
    Page 2 · response
    Published 5 March 2017

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Implement weekly wing-manager and monthly Duty Governor quality checks of ACCT and post-closure reviews, including caremap assessment and corrective feedback.

    Verbatim wording from the response

    “In order to provide assurance that new procedures are fully embedded and effective, a review of the establishment’s ACCT quality assurance processes took place in 2016. This led to the introduction of two new quality checks, one undertaken weekly by the wing manager and the other on a monthly basis by the Duty Governor, which assess the quality and completeness of ACCT reviews and post-closure reviews. Both checks include a section which requires managers to assess and comment specifically on the quality of caremaps, and where deficiencies are found, feedback is given to the case manager and/or wing manager who are required to take the appropriate action to rectify this.”

    Source location

    2017-0049-Response-by-NOMS
    Page 2 · response
    Published 5 March 2017

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Develop the family pathway during the May/June 2017 policy review to support active family involvement wherever possible.

    Verbatim wording from the response

    “During 2016 the prison has sought to further raise awareness of the value and importance of family contact and has seen significant improvement. Family members have been invited to and attended ACCT reviews, made telephone contributions and been involved in release planning for those prisoners on open ACCTs. The Safer Prisons team is planning further work with Case Managers using some of the local examples with contributions from family members and prisoners. During the review of the local Safer Prisons Policy in May/June 2017 the ‘family pathway’ will be developed to ensure active involvement of families wherever possible.”

    Source location

    2017-0049-Response-by-NOMS
    Page 2 · response
    Published 5 March 2017

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Share immediate complex-case resettlement concerns with relevant departments by telephone and record them in prisoner case notes to address safeguarding issues.

    Verbatim wording from the response

    “It has also been agreed at the multi-agency meetings that any immediate concerns regarding resettlement issues in complex cases will be shared with relevant departments by an immediate phone call, and recorded on the prisoner case notes. This is to identify and address safeguarding issues, such as prisoners with accommodation issues and those suffering with mental health concerns.”

    Source location

    2017-0049-Response-by-NOMS
    Page 3 · response
    Published 5 March 2017

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Undertake further Case Manager work using local examples and contributions from families and prisoners to promote family involvement.

    Verbatim wording from the response

    “During 2016 the prison has sought to further raise awareness of the value and importance of family contact and has seen significant improvement. Family members have been invited to and attended ACCT reviews, made telephone contributions and been involved in release planning for those prisoners on open ACCTs. The Safer Prisons team is planning further work with Case Managers using some of the local examples with contributions from family members and prisoners. During the review of the local Safer Prisons Policy in May/June 2017 the ‘family pathway’ will be developed to ensure active involvement of families wherever possible.”

    Source location

    2017-0049-Response-by-NOMS
    Page 2 · response
    Published 5 March 2017

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Route all future disclosure to the Coroner’s Court through Government Legal Department to avoid confusion.

    Verbatim wording from the response

    “Disclosure We regret that the provision of documents to this inquest was not achieved in the way that we would wish, and would like to apologise to you for the impact that this had on the inquest process. Much of this difficulty arose from the fact that, as Mr Portland died some months after his release from HMP Woodhill and when he was not in prison custody, the usual process by which prisons ensure that the paperwork required for disclosure to assist the Prison and Probation Ombudsman’s investigation and the Coroner’s Inquest is collated was not initiated. In consultation with GLD, we have agreed that in future all disclosure to the Coroner’s Court will be done through GLD to avoid confusion.”

    Source location

    2017-0049-Response-by-NOMS
    Page 3 · response
    Published 5 March 2017

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review the complex-case database in July 2017 for fitness for purpose and assess how information sharing supports vulnerable prisoners approaching release.

    Verbatim wording from the response

    “release, for example with GPs, drug services and housing. This ensures that no referrals are being repeated and that everyone involved in the resettlement plan is fully aware of ongoing and required actions. The use of the database will be reviewed in July 2017 to ensure that it is fit for purpose and to consider how this information sharing is used to provide multi-disciplinary support to the most vulnerable and at risk individuals approaching release.”

    Source location

    2017-0049-Response-by-NOMS
    Page 3 · response
    Published 5 March 2017

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Enable prisoners to register with a GP before release, including timely transfer of clinical information and active registration support.

    Verbatim wording from the response

    “From July 2017, prisoners will be able to register with a GP practice before they leave prison. The agreement includes the timely transfer of clinical information from the prison to the GP practice, with an emphasis on medication history and substance misuse management plans, to enable better care when a new patient first presents at the practice. Prisoners will be actively supported to register with a GP.”

    Source location

    2017-0049-Response-by-NOMS
    Page 3 · response
    Published 5 March 2017

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Use a shared complex-case database to coordinate resettlement planning and live information sharing among the establishment and relevant support providers.

    Verbatim wording from the response

    “Since Mr Portland’s release from HMP Woodhill, the prison has introduced a new database system for the management of complex cases, which allows for the live sharing of information between the establishment, the CRC, Westminster Drug Project (the providers of substance misuse support) and CNWL. The database allows a coordinated approach to resettlement planning, providing information relating to any concerns or issues and appointments upon”

    Source location

    2017-0049-Response-by-NOMS
    Page 2 · response
    Published 5 March 2017

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Community Rehabilitation Companies are responsible for resettlement services for prisoners serving 12 months or less.

    Verbatim wording from the response

    “Discharge Since 1 June 2014 the provision of resettlement services for prisoners serving 12 months and under has been the responsibility of Community Rehabilitation Companies (CRCs). The prison works closely with the provider of resettlement services at HMP Woodhill, MTC Novo CRC, which is required to provide support services relating to housing and accommodation, employment training and education, finance benefit and debt.”

    Source location

    2017-0049-Response-by-NOMS
    Page 2 · response
    Published 5 March 2017

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The prison can only prompt family contact, and effective involvement depends on the prisoner’s consent.

    Verbatim wording from the response

    “Family contact The value of family involvement for prisoners, and the significant resettlement opportunities that contact with family members presents, are recognised. However, the prison can only prompt this contact (and it could only be effective) with the consent of the prisoner.”

    Source location

    2017-0049-Response-by-NOMS
    Page 2 · response
    Published 5 March 2017

    Open published response

  7. Milton Keynes

    AI-generated summary

    Ian Keith Brown · 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

    Ian Keith Brown, who had mental illness and was on remand at HMP Woodhill, was found in his cell with a belt ligature around his neck on 19 July 2015 and was pronounced dead at 14:00 hours. Concerns were raised that recommendations to improve suicide and self-harm prevention, including ACCT case management and a prison-wide strategy, had not been implemented sufficiently, while suicides and self-harm at HMP Woodhill continued to rise.

    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 Woodhill Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Rising numbers of suicides and self-harm deaths in the prison

    Wider context from the report

    “(1)During the course of the evidence I was referred to the most recent report from the HM Inspector of Prisons that highlighted “Recommendations made by the Prisons and Probation Ombudsman following previous deaths in custody, such as the need to improve the quality of ACCT case management documentation for prisoners at risk of suicide or self harm, had not been implemented with sufficient rigour. (2) Deaths at the prison from suicide and self harm continue to rise. (3) The recommendation from the Inspectors is that there should be a “prison-wide strategy and action plan to reduce the number of self inflicted deaths and incidents of self harm should be developed urgently. This should be based on detailed data and trend analysis and include implementation of Prison and Probation Ombudsman recommendations. It should also include improvements in the quality of ACCT case management documentation, and the lessons learned from internal investigations into life-threatening incidents.” I have concerns that the recommendations will not be implemented and that past recommendations have been ignored. (4) That despite my previous PFD reports the number of suicides at HMP Woodhill continue to rise. ”
    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 Woodhill Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to maintain adequate ACCT case management documentation

    Wider context from the report

    “(1)During the course of the evidence I was referred to the most recent report from the HM Inspector of Prisons that highlighted “Recommendations made by the Prisons and Probation Ombudsman following previous deaths in custody, such as the need to improve the quality of ACCT case management documentation for prisoners at risk of suicide or self harm, had not been implemented with sufficient rigour. (2) Deaths at the prison from suicide and self harm continue to rise. (3) The recommendation from the Inspectors is that there should be a “prison-wide strategy and action plan to reduce the number of self inflicted deaths and incidents of self harm should be developed urgently. This should be based on detailed data and trend analysis and include implementation of Prison and Probation Ombudsman recommendations. It should also include improvements in the quality of ACCT case management documentation, and the lessons learned from internal investigations into life-threatening incidents.” I have concerns that the recommendations will not be implemented and that past recommendations have been ignored. (4) That despite my previous PFD reports the number of suicides at HMP Woodhill continue to rise. ”
    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 Woodhill Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to implement previous safety recommendations

    Wider context from the report

    “(1)During the course of the evidence I was referred to the most recent report from the HM Inspector of Prisons that highlighted “Recommendations made by the Prisons and Probation Ombudsman following previous deaths in custody, such as the need to improve the quality of ACCT case management documentation for prisoners at risk of suicide or self harm, had not been implemented with sufficient rigour. (2) Deaths at the prison from suicide and self harm continue to rise. (3) The recommendation from the Inspectors is that there should be a “prison-wide strategy and action plan to reduce the number of self inflicted deaths and incidents of self harm should be developed urgently. This should be based on detailed data and trend analysis and include implementation of Prison and Probation Ombudsman recommendations. It should also include improvements in the quality of ACCT case management documentation, and the lessons learned from internal investigations into life-threatening incidents.” I have concerns that the recommendations will not be implemented and that past recommendations have been ignored. (4) That despite my previous PFD reports the number of suicides at HMP Woodhill continue to rise. ”
    Open source report
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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

14%
14%All other recipients 58%
0%100%

How actions were described at the time

This respondent
33%17%50%
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

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