Recipient

Wormwood Scrubs Prison

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First report 3 Mar 2014•Latest report 28 May 2025

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
6

Naming this recipient

Published responses
17%

Found for named reports

Concerns addressed
2

Across all linked responses

Stated actions
2

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.

17%published responses found
2stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

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

  1. West London

    AI-generated summary

    Samuel Anthony Donald STEWART · 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

    Samuel Stewart was found deceased in his cell at HMP Wormwood Scrubs on 15 July 2023, with drugs paraphernalia in the cell. His death was due to drugs in combination with long-term cardiac damage. A positive drug test on 6 March 2023 was not followed by discussion, support, or a multidisciplinary meeting, and the pathways after a positive result were unclear or not followed.

    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 Wormwood Scrubs Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to support and discuss positive drug test results with prisoners

    Wider context from the report

    “Sam had elected to have a place on a "drug free" wing and accepted the conditions of this placement. He accessed non-prescribed drugs (amphetamines) as his test on 6 March 2023 yielded a positive result. No action was taken by either the prison or healthcare. (1) consideration should be given as to what actions should have been taken, and if this is set out in the national or local policy guidelines (2) pathways after a positive test result were either not followed or unclear (3) An opportunity was missed to support Sam and discuss this with him ”
    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 Wormwood Scrubs Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to ensure clear and followed pathways for action after a positive drug test

    Wider context from the report

    “Sam had elected to have a place on a "drug free" wing and accepted the conditions of this placement. He accessed non-prescribed drugs (amphetamines) as his test on 6 March 2023 yielded a positive result. No action was taken by either the prison or healthcare. (1) consideration should be given as to what actions should have been taken, and if this is set out in the national or local policy guidelines (2) pathways after a positive test result were either not followed or unclear (3) An opportunity was missed to support Sam and discuss this with him ”
    Open source report

  2. West London

    AI-generated summary

    Isaiah Adekunle OLUGOSI · 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

    Isaiah Adekunle OLUGOSI died by suicide after hanging himself in his prison cell overnight on 27/28 March 2022. His wife and police were unable to contact the prison because calls were diverted to an unmanned or obsolete number, while the prison’s buzzer/intercom system was out of action. The jury found that the failure to provide a working buzzer/intercom system was a failure, and the report raised concern that the prison or Ministry of Justice still considered it unnecessary.

    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 Wormwood Scrubs Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to recognise the necessity of a working buzzer/intercom system

    Wider context from the report

    “The buzzer/intercom system must have been provided because it was thought important to provide that additional means of communication between the prison and the outside world. In this case, a working system would have enabled the Deceased's wife to warn the prison of his impending suicide. This could happen again in the future if there was another problem with the telephone system during the night state. It is difficult to understand why the buzzer/intercom system has not worked for several years. There was evidence that it is irreparable. But the proposed solution appeared to be either to leave it as it is (still not working) or to remove it altogether. The jury found that the failure to provide a working buzzer/intercom system was a failure. It is a matter of concern that the prison/the Ministry of Justice still considers that it is unnecessary. ”
    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 Wormwood Scrubs Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to provide a working buzzer/intercom system

    Wider context from the report

    “The buzzer/intercom system must have been provided because it was thought important to provide that additional means of communication between the prison and the outside world. In this case, a working system would have enabled the Deceased's wife to warn the prison of his impending suicide. This could happen again in the future if there was another problem with the telephone system during the night state. It is difficult to understand why the buzzer/intercom system has not worked for several years. There was evidence that it is irreparable. But the proposed solution appeared to be either to leave it as it is (still not working) or to remove it altogether. The jury found that the failure to provide a working buzzer/intercom system was a failure. It is a matter of concern that the prison/the Ministry of Justice still considers that it is unnecessary. ”
    Open source report

  3. West London

    AI-generated summary

    Harold Chukwudemu Uzomechina · 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

    Harold Chukwudemu Uzomechina died in prison on 24 April 2016 after being found unresponsive in his cell and not responding to CPR. The inquest concluded that he died a drug-related death, with failure to recognise signs of cardio-respiratory depression contributing. Concerns included inadequate overnight physical monitoring and differing levels of care and attention for detainees in the substance misuse unit compared with those formerly on an ACCT.

    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 Wormwood Scrubs Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to provide at-risk substance misuse unit detainees with the same level of care and attention as former ACCT detainees

    Wider context from the report

    “2. The totality of the evidence given by staff suggests that the at-risk population of detainees on the substance misuse unit were not afforded the same level care and attention given to detainees who were formerly on an ACCT. This needs to be addressed. ”
    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 Wormwood Scrubs Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Unavailability of dedicated prison officers for substance misuse unit detainees at night

    Wider context from the report

    “1. There appeared to be differential treatment of detainees on the substance misuse unit at night compared to treatment they received during the day – specifically, detainees had the benefit of dedicated prison officers during the day time but not during the night. ”
    Open source report

  4. London (West)

    AI-generated summary

    John Kevin O’MEARA · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    John Kevin O’MEARA suffered respiratory failure and died on 29 March 2016 in a cell at HM Prison Wormwood Scrubs. The report identifies insufficient staffing, inadequate medical monitoring, and a missed opportunity to raise concerns about his health. It also raises concerns about delays in activating emergency codes and the availability of trained passive dogs to help control novel psychoactive substances in prisons.

    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 Wormwood Scrubs Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to immediately activate the Code Blue/Red system

    Wider context from the report

    “Activation of Code Blue/Red The sad facts leading up to the death of John Kevin O’MEARA have not been the first set of facts where I have heard about a death where the activation of codes has not been immediate. I am concerned that Prison Officers are not strictly following the Code Blue/Red system which is meaning there is a delay in the London Ambulance being called. Whilst I can see in many cases that, by the time the prisoner has been found, there may be nothing that can be done to resuscitate them with the number of deaths happening relating to opiate use, the prompt administration of Naloxone is important to give the deceased the best chance; and this is only one responsive measure. I gather the current way that Officers are trained is by the use of Notices and Pocket-sized Cards. The Officer finding Mr O’Meara, even after questioning by myself and the Counsel for Interested Persons, left the witness stand still not understanding that by not immediately calling a Code Blue, and despite prison medical staff coming quickly, an ambulance would not have been called. Even presumably having reflected on the case, she did not appear to understand the reason why a Code is called. I am asking for more consideration to be given to ensure the right message is getting across and that Prison Officers understand the importance of and reasons for the use of the codes. ”
    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 Wormwood Scrubs Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of officer training to ensure understanding of the importance and reasons for Code Blue/Red use

    Wider context from the report

    “Activation of Code Blue/Red The sad facts leading up to the death of John Kevin O’MEARA have not been the first set of facts where I have heard about a death where the activation of codes has not been immediate. I am concerned that Prison Officers are not strictly following the Code Blue/Red system which is meaning there is a delay in the London Ambulance being called. Whilst I can see in many cases that, by the time the prisoner has been found, there may be nothing that can be done to resuscitate them with the number of deaths happening relating to opiate use, the prompt administration of Naloxone is important to give the deceased the best chance; and this is only one responsive measure. I gather the current way that Officers are trained is by the use of Notices and Pocket-sized Cards. The Officer finding Mr O’Meara, even after questioning by myself and the Counsel for Interested Persons, left the witness stand still not understanding that by not immediately calling a Code Blue, and despite prison medical staff coming quickly, an ambulance would not have been called. Even presumably having reflected on the case, she did not appear to understand the reason why a Code is called. I am asking for more consideration to be given to ensure the right message is getting across and that Prison Officers understand the importance of and reasons for the use of the codes. ”
    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 Wormwood Scrubs Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Insufficient availability of trained passive dogs for controlling Novel Psychoactive Substance use in prisons

    Wider context from the report

    “Passive Dog Use The Prison GP expert in this inquest was emphatic that Novel Psychoactive Substance played a part in the death. I understand that these drugs can be brought into the prison in a number of ways and one is NPS contaminated paper or even childrens’ photographs, arriving into Prisons in the post. I appreciate how challenging it is to control the use of Novel Psychoactive Substances in prisons. So, the use of trained passive dogs is particularly helpful In fact it appears to be one of the only failsafe ways to controlling NPS use in prisons. There are only two at HMP Wormwood Scrubs whereas HMP Highdown has eight. Although dogs can be ‘borrowed’ from other London prisons when handlers are away, I wish to put on record my support for funding for more of these dogs at this current challenging time. ”
    Open source report

  5. West London

    AI-generated summary

    Blaise Francis Farry · 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

    Blaise Francis Farry died by suicide after hanging himself from a ligature made from a bed sheet suspended from a prison window on 19 January 2013. The jury identified inadequate exchange of information between healthcare and prison staff in the weeks before his death, and evidence indicated insufficient staffing to institute a nominated Officer scheme despite previous reports identifying the need for one.

    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 Wormwood Scrubs Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Insufficient staffing levels for instituting a nominated officer scheme

    Wider context from the report

    “Evidence heard that indicated that staffing levels were insufficient to allow for a nominated Officer scheme to be instituted. The Prisons Ombudsman had made previous reports identifying the need for such a scheme but HMP Wormwood Scrubs had not instituted it. ”
    Open source report

  6. West London

    AI-generated summary

    Lee Sean MACPHERSON · 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

    Lee Sean MACPHERSON was found dead in a safer custody cell at HMP Wormwood Scrubs on 17 October 2012, after being remanded into custody the previous afternoon. Concerns related to incomplete and inconsistently transferred police risk-assessment and escort handover documentation between the police, SERCO and prison staff.

    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 Wormwood Scrubs Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to complete escort handover details on the PER

    Wider context from the report

    “(3) The escort handover details on the PER were not completed by the prison staff (or SERCO staff which is a matter SERCO have already addressed). ”
    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 Wormwood Scrubs Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to ensure that police documentation recorded as accompanying the PER is available to escort staff

    Wider context from the report

    “(2) There was a lack of common understanding between SERCO staff and prison staff about what police documentation, including the police risk assessment, accompanied a person in custody, in addition to the PER. Boxes on the PER had been ticked indicating that, among other things, it was accompanied by a police risk assessment but SERCO staff said they had not seen that or the other documents. ”
    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 Wormwood Scrubs Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of shared understanding about police documentation accompanying persons in custody

    Wider context from the report

    “(2) There was a lack of common understanding between SERCO staff and prison staff about what police documentation, including the police risk assessment, accompanied a person in custody, in addition to the PER. Boxes on the PER had been ticked indicating that, among other things, it was accompanied by a police risk assessment but SERCO staff said they had not seen that or the other documents. ”
    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 Wormwood Scrubs Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to complete and provide the police risk assessment before custody escort

    Wider context from the report

    “(1) The police risk assessment was not completed until the deceased had already been collected by SERCO and it was a police risk assessment completed in the early hours of the morning that found its way to the prison. ”
    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

17%
17%All other recipients 58%
0%100%

How actions were described at the time

This respondent
100%
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