PFD report

IAN JAMES WEEKS · Prevention of Future Deaths report

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Issued 12 Mar 2020•South Wales Central

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
3

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised2

  1. Failure to review System 1 and medical records on prison admission
    Part of recurring concern: Failure to review relevant clinical records before care decisionsPart of recurring concern: Unreliable transfer and consideration of medical information during custody transitions
  2. Failure to identify and continue prescribed antidepressant treatment on admission
    Part of recurring concern: Unreliable medication reconciliation across care transitions
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    Implementing a red-flag system requires partnership with the technology provider, health authorities and other prisons because it would affect all prisons.

    Stated by Cardiff & Vale University LHBRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to review System 1 and medical records on prison admission

Wider context from the report

“(1) Although it was recorded on System 1 that Mr Weeks had recently attempted suicide in another prison shortly before his admission to HMP Cardiff no member of Healthcare staff checked the medical records and further that although the GP records which were sent to the prison confirmed that Mr Weeks was prescribed anti-depressants in the community no member of Healthcare staff noticed this and as a consequence Mr Weeks was not given anti-depressants in HMP Cardiff. The Healthcare witnesses, including the Head of Healthcare, indicated that a red flag for suicide or self-harm would be of great value for staff who because of insufficient staff and a heavy workload did not have time to review the System 1 record in any or any sufficient detail. Further it was considered that all System 1 records should be reviewed when an individual is admitted into the prison and that there should be in place a process for doing so. ”

Is this part of a recurring concern?

Yes — Failure to review relevant clinical records before care decisions; Unreliable transfer and consideration of medical information during custody transitions.

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Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to identify and continue prescribed antidepressant treatment on admission

Wider context from the report

“(1) Although it was recorded on System 1 that Mr Weeks had recently attempted suicide in another prison shortly before his admission to HMP Cardiff no member of Healthcare staff checked the medical records and further that although the GP records which were sent to the prison confirmed that Mr Weeks was prescribed anti-depressants in the community no member of Healthcare staff noticed this and as a consequence Mr Weeks was not given anti-depressants in HMP Cardiff. The Healthcare witnesses, including the Head of Healthcare, indicated that a red flag for suicide or self-harm would be of great value for staff who because of insufficient staff and a heavy workload did not have time to review the System 1 record in any or any sufficient detail. Further it was considered that all System 1 records should be reviewed when an individual is admitted into the prison and that there should be in place a process for doing so. ”

Is this part of a recurring concern?

Yes — Unreliable medication reconciliation across care transitions.

Open source report

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

Implementing a red-flag system requires partnership with the technology provider, health authorities and other prisons because it would affect all prisons.

Verbatim wording from the response

“In order to pursue a red flag system, a partnership with TPP (SystmOne technology provider), NHS England, NHS Wales Informatics Service (NWIS) and other prisons will be required as this would be a change that would affect all prisons. The clinical team from HMP Cardiff intend to raise this issue at their next All Wales Prison Healthcare Meeting which Public Health Wales and Welsh Government also attend.”

Source location

2020-0064-Response-from-Cardiff-and-Vale-NHS-Trust-1
Page 2 · response
Published 27 March 2020

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Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation

Existing dual screening reviews, supported by prison staff reviewing records and sharing important information, are considered sufficient for new admissions.

Verbatim wording from the response

“As indicated, a large volume of information is contained within SystmOne. Existing process is for healthcare staff in the prison to undertake two screening reviews of new individuals in order to assess and plan their care. This is done in conjunction with prison staff who also review the SystmOne records and share important information.”

Source location

2020-0064-Response-from-Cardiff-and-Vale-NHS-Trust-1
Page 3 · response
Published 27 March 2020

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.3

  1. 1

    Secure funding for an IT and data specialist role to improve prison healthcare information technology.

    Stated by Cardiff & Vale University LHBStated completedThe respondent said that this action was complete when they made their response on 27 March 2020.
  2. 2

    Raise development of a prison-wide red-flag system at the next All Wales Prison Healthcare Meeting.

    Stated by Cardiff & Vale University LHBStated plannedThe respondent said that this action was planned when they made their response on 27 March 2020.
  3. 3

    Implement a process for clinical documentation audits in 2020.

    Stated by Cardiff & Vale University LHBStated plannedThe respondent said that this action was planned when they made their response on 27 March 2020.

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

Secure funding for an IT and data specialist role to improve prison healthcare information technology.

Verbatim wording from the response

“The team has recently gained funding for an IT / data specialist. Recruitment to this role will be pursued once a workforce review is complete. The post holder will have a key role in progressing work with NWIS to improve IT in the prison. This work has an important part to play in assisting clinical staff in their care of men in the prison.”

Source location

2020-0064-Response-from-Cardiff-and-Vale-NHS-Trust-1
Page 3 · response
Published 27 March 2020

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

Raise development of a prison-wide red-flag system at the next All Wales Prison Healthcare Meeting.

Verbatim wording from the response

“In order to pursue a red flag system, a partnership with TPP (SystmOne technology provider), NHS England, NHS Wales Informatics Service (NWIS) and other prisons will be required as this would be a change that would affect all prisons. The clinical team from HMP Cardiff intend to raise this issue at their next All Wales Prison Healthcare Meeting which Public Health Wales and Welsh Government also attend.”

Source location

2020-0064-Response-from-Cardiff-and-Vale-NHS-Trust-1
Page 2 · response
Published 27 March 2020

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 a process for clinical documentation audits in 2020.

Verbatim wording from the response

“SystmOne has been used for many years in the prison setting and there is therefore a great deal of legacy information within it, the quality of which has been variable over the course of time but on an improving trajectory. The team recognises the importance of sound clinical documentation and will ensure they implement a process of clinical documentation audits in 2020.”

Source location

2020-0064-Response-from-Cardiff-and-Vale-NHS-Trust-1
Page 2 · response
Published 27 March 2020

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026