PFD report

Matthew David Harris · Prevention of Future Deaths report

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Issued 21 Jun 2023•Worcestershire

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
2

Of 1 recipient

Stated actions
7

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. Failure to record suicidal ideation on Person Escort Records and Suicide and Self-Harm Warning forms
    Part of recurring concern: Failure to reliably escalate suicidal intent informationPart of recurring concern: Unreliable completion and transfer of Prisoner Escort RecordsPart of recurring concern: Unreliable recording of significant incidents and disclosures
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.3

  1. Action

    Remind investigators to inform custody officers about disclosures relevant to ongoing risk management.

    Stated by Dyfed-Powys PoliceStated completedThe respondent said that this action was complete when they made their response on 6 September 2023.
  2. Action

    Inform investigation and custody staff, anonymously, about the omission of relevant suicidal-ideation information.

    Stated by Dyfed-Powys PoliceStated completedThe respondent said that this action was complete when they made their response on 6 September 2023.
  3. Action

    Instruct custody officers to ask interviewing officers about information relevant to ongoing detainee risk assessment.

    Stated by Dyfed-Powys PoliceStated completedThe respondent said that this action was complete when they made their response on 6 September 2023.

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 record suicidal ideation on Person Escort Records and Suicide and Self-Harm Warning forms

Wider context from the report

“(1) Following his arrest, and before he was interviewed about the alleged offence of murder, Mr. Harris was assessed by a consultant forensic psychiatrist, ████████ concluded that Mr. Harris was fit to be detained and fit to be interviewed, he did not possible symptoms of Post Traumatic Stress Disorder, likely due to some trauma in Mr. Harris’ background, possible symptoms of a personality disorder, and “potentially a psychotic process, with potential underlying delusional beliefs”; (2) During his police interview on 14.5.22, when describing his movements before the alleged murder had taken place, Mr. Harris told officers he had ████████ intending to jump off in order to take his own life, but had decided against it because “I thought no, I’ve got to reveal all this first”; (3) Despite the fact that these comments revealed very recent suicidal ideation on Mr. Harris’ part, no mention of them appears to have been made in any of the following documents: (a) The Person Escort Record ( PER ) and Suicide and Self-Harm ( SASH ) Warning forms which accompanied Mr. Harris from police custody at Haverfordwest Police Station to Haverfordwest Magistrates’ Court on 16.5.22; (b) The PER and SASH Warning forms which accompanied Mr. Harris from Haverfordwest Magistrates’ Court to HMP Swansea later that same day. (4) Although I was quite satisfied that the omission of these comments from the above documents made no difference to the sad outcome in this case, I am concerned that the failure by Dyfed-Powys Police officers to realise that such comments ought to be included on a PER and SASH Warning form, if repeated in future, may lead to a person in custody’s risk of suicide and/or self-harm, being either underestimated, or ignored completely. ”

Is this part of a recurring concern?

Yes — Failure to reliably escalate suicidal intent information; Unreliable completion and transfer of Prisoner Escort Records; Unreliable recording of significant incidents and disclosures.

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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

Remind investigators to inform custody officers about disclosures relevant to ongoing risk management.

Verbatim wording from the response

“Further, investigators have been reminded of their duty to inform the custody officer of any information disclosed to them that should be considered as part of ongoing risk management.”

Source location

Response from Dyfed-Powys Police
Page 2 · response
Published 6 September 2023

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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

Inform investigation and custody staff, anonymously, about the omission of relevant suicidal-ideation information.

Verbatim wording from the response

“To confirm, on 1st August 2023 via my Head of Custody Services, all staff involved in investigations and those responsible for the care of detainees whilst in police custody have been informed, in an anonymized manner, of the nature of the omission in this case.”

Source location

Response from Dyfed-Powys Police
Page 2 · response
Published 6 September 2023

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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

Instruct custody officers to ask interviewing officers about information relevant to ongoing detainee risk assessment.

Verbatim wording from the response

“Custody Officers have been instructed to specifically ask interviewing officers whether they have any information that is relevant to the ongoing duty of risk assessment; information needed to best manage the welfare of the detainee.”

Source location

Response from Dyfed-Powys Police
Page 2 · response
Published 6 September 2023

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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.4

  1. 1

    Roll out further ACCT training to all case managers and continue training on consistent case management, information sharing, and record keeping.

    Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 6 September 2023.
  2. 2

    Discuss assurance findings at safety custody meetings and disseminate them through daily Governor Reports to staff.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 6 September 2023.
  3. 3

    Publish bi-monthly Governor Orders and Notices to Staff reinforcing effective ACCT case management.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 6 September 2023.
  4. 4

    Implement a comprehensive ACCT assurance procedure with dedicated officer reviews, random management checks, and prompt resolution of inconsistencies.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 6 September 2023.

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

Roll out further ACCT training to all case managers and continue training on consistent case management, information sharing, and record keeping.

Verbatim wording from the response

“Further ACCT training is currently being rolled out to all ACCT case managers at HMP Swansea, which highlights the importance of consistency in case management, information sharing, and record keeping. We are committed to ensuring ACCT management remains a key focus of our work and so training in this area will be continuous.”

Source location

Response from HM Prison and Probation Service
Page 1 · response
Published 6 September 2023

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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

Discuss assurance findings at safety custody meetings and disseminate them through daily Governor Reports to staff.

Verbatim wording from the response

“The findings from the assurance checks are now discussed at safety custody meetings to identify common themes and inform improvements, and are included on the prison duty Governor Reports, which are sent daily to all HMP Swansea staff. Further to this, Governor Orders and Notices to Staff are published on a bi-monthly basis to stress the importance of effective ACCT case management.”

Source location

Response from HM Prison and Probation Service
Page 1 · response
Published 6 September 2023

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

Publish bi-monthly Governor Orders and Notices to Staff reinforcing effective ACCT case management.

Verbatim wording from the response

“The findings from the assurance checks are now discussed at safety custody meetings to identify common themes and inform improvements, and are included on the prison duty Governor Reports, which are sent daily to all HMP Swansea staff. Further to this, Governor Orders and Notices to Staff are published on a bi-monthly basis to stress the importance of effective ACCT case management.”

Source location

Response from HM Prison and Probation Service
Page 1 · response
Published 6 September 2023

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 comprehensive ACCT assurance procedure with dedicated officer reviews, random management checks, and prompt resolution of inconsistencies.

Verbatim wording from the response

“HMP Swansea have reviewed the management of the ACCT process and introduced a thorough ACCT assurance procedure to ensure there is consistency and effective completion of all ACCT documents. A dedicated safer custody officer now conducts a comprehensive review of all open ACCT documents to ensure they are completed in line with national policy. A number of additional checks are included in this process, with a random sample also conducted by custodial managers and the senior management team. This ensures that any inconsistencies or issues are addressed almost immediately.”

Source location

Response from HM Prison and Probation Service
Page 1 · response
Published 6 September 2023

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