PFD report

Angela Christine Thompson · Prevention of Future Deaths report

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Issued 7 Oct 2025•East Riding and Hull

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.

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Concerns
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
10

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 raised1

  1. Lack of liaison between prison medical services and local psychiatric services for prisoners with ongoing psychiatric issues at release
    Part of recurring concern: Failure to maintain healthcare continuity for prisoners after release
Responses linked to these concerns

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

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.9

  1. Action

    Review and develop liaison arrangements specifically for releases to geographically distant areas.

    Stated by HMPPS – Probation Service (Yorkshire & the Humber)Stated plannedThe respondent said that this action was planned when they made their response on 21 January 2026.
  2. Action

    Hold multidisciplinary meetings with prison, primary-care and community teams to formulate transition support for complex prisoners and people who self-harm.

    Stated by HMPPS – Probation Service (Yorkshire & the Humber)Stated completedThe respondent said that this action was complete when they made their response on 21 January 2026.
  3. Action

    Share learning from the death across HMPPS regions and regional Health & Justice Teams.

    Stated by HMPPS – Probation Service (Yorkshire & the Humber)Stated plannedThe respondent said that this action was planned when they made their response on 21 January 2026.

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

Lack of liaison between prison medical services and local psychiatric services for prisoners with ongoing psychiatric issues at release

Wider context from the report

“Evidence was heard that in some instances within the prison estate of England and Wales, there may be a lack of liaison in patients who have on-going psychiatric issues at the time of release from custody between the prison medical services and the psychiatric services in the area where the released prisoner lives. This was felt to be of particular concern when a person is incarcerated at a prison geographically distant from their home address. Evidence suggested that such liaison would ensure and enhance continuity of care following release from prison. ”

Is this part of a recurring concern?

Yes — Failure to maintain healthcare continuity for prisoners after release.

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Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Review and develop liaison arrangements specifically for releases to geographically distant areas.

Verbatim wording from the response

“It is acknowledged that a release from custody to a different geographical area is more complex and learning from the circumstances of this sad death will be shared across all HMPPS Regions to ensure liaison work can be reviewed and developed specifically to deal with this situation.”

Source location

Response from HM Prison & Probation Service
Page 1 · response
Published 21 January 2026

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Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Hold multidisciplinary meetings with prison, primary-care and community teams to formulate transition support for complex prisoners and people who self-harm.

Verbatim wording from the response

“Multidisciplinary meetings are regularly held in relation to complex prisoners and those who engage in self-harming behaviours, these are held with primary care, prison and community teams where appropriate to formulate avenues of support during the transition from prison to the community.”

Source location

Response from HM Prison & Probation Service
Page 1 · response
Published 21 January 2026

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 learning from the death across HMPPS regions and regional Health & Justice Teams.

Verbatim wording from the response

“It is acknowledged that a release from custody to a different geographical area is more complex and learning from the circumstances of this sad death will be shared across all HMPPS Regions to ensure liaison work can be reviewed and developed specifically to deal with this situation.”

Source location

Response from HM Prison & Probation Service
Page 1 · response
Published 21 January 2026

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

Operate Regional Health & Justice Teams to improve integrated health services and liaison for people under probation supervision, including prison leavers.

Verbatim wording from the response

“At an operational level, within HMPPS, there are now Regional Health & Justice Teams that sit within Probation Community Integration. One of the aims of these teams is to work with NHS England, Integrated Care Boards and Heads of Service in Probation to improve integrated health services for anyone subject to Probation supervision, including prison leavers.”

Source location

Response from HM Prison & Probation Service
Page 1 · response
Published 21 January 2026

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Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Use the central Data Insights Under Supervision Team to support cross-service learning, develop liaison capability and monitor action plans arising from PPO reports.

Verbatim wording from the response

“HMPPS has also created a central Data Insights Under Supervision Team which supports the delivery of learning across Prisons and Probation to develop confidence and skills to improve liaison between”

Source location

Response from HM Prison & Probation Service
Page 1 · response
Published 21 January 2026

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 learning from the death across HMPPS regions and regional Health and Justice Teams.

Verbatim wording from the response

“It is acknowledged that a release from custody to a different geographical area is more complex and learning from the circumstances of this sad death will be shared across all HMPPS Regions to ensure liaison work can be reviewed and developed specifically to deal with this situation.”

Source location

Response from HM Prison & Probation Service
Page 1 · response
Published 21 January 2026

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 and develop liaison arrangements for releases to geographically different areas, using learning from the death.

Verbatim wording from the response

“It is acknowledged that a release from custody to a different geographical area is more complex and learning from the circumstances of this sad death will be shared across all HMPPS Regions to ensure liaison work can be reviewed and developed specifically to deal with this situation.”

Source location

Response from HM Prison & Probation Service
Page 1 · response
Published 21 January 2026

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

Operate the central Deaths Under Supervision Team to support cross-service learning, improve prison-community liaison skills, and monitor implementation of action plans.

Verbatim wording from the response

“HMPPS has also created a central Deaths Under Supervision Team which supports the delivery of learning across Prisons and Probation to develop confidence and skills to improve liaison between”

Source location

Response from HM Prison & Probation Service
Page 1 · response
Published 21 January 2026

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

Hold multidisciplinary meetings with prison, primary care and community teams to formulate transition support for complex prisoners and people who self-harm.

Verbatim wording from the response

“Multidisciplinary meetings are regularly held in relation to complex prisoners and those who engage in self-harming behaviours, these are held with primary care, prison and community teams where appropriate to formulate avenues of support during the transition from prison to the community.”

Source location

Response from HM Prison & Probation Service
Page 1 · response
Published 21 January 2026

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.1

  1. 1

    Operate Regional Health and Justice Teams to improve integrated health services for people under probation supervision, including prison leavers.

    Stated by HMPPS – Probation Service (Yorkshire & the Humber)Stated completedThe respondent said that this action was complete when they made their response on 21 January 2026.

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

Operate Regional Health and Justice Teams to improve integrated health services for people under probation supervision, including prison leavers.

Verbatim wording from the response

“At an operational level, within HMPPS, there are now Regional Health & Justice Teams that sit within Probation Community Integration. One of the aims of these teams is to work with NHS England, Integrated Care Boards and Heads of Service in Probation to improve integrated health services for anyone subject to Probation supervision, including prison leavers.”

Source location

Response from HM Prison & Probation Service
Page 1 · response
Published 21 January 2026

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