PFD report

Daniel Brendan Byrne · Prevention of Future Deaths report

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Issued 14 Dec 2015•Milton Keynes

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: 2
Recipients: 2
Responses found: 2
Stated actions: 20

Recipients and published responses

Central and North West London NHS Foundation TrustResponse found HM Prison and Probation Service

Response found

Source document

Full report text

This is the full text from the original published report.

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Investigation and inquest

On 2nd March 2015 I commenced an investigation into the death of Daniel Brendan Byrne, aged 28. The investigation concluded at the end of the inquest on 14th December 2015. The conclusion of the inquest was that ‘There was a failure by both the healthcare staff and prison officers to carry out an adequate risk assessment for self harm and suicide. There was a failure to refer Daniel Byrne for an urgent mental health assessment. There was a failure to carry out the first ACCT case review adequately. Daniel Byrne deliberately chose to suspend himself by a ligature but we are not satisfied that he intended that the outcome be fatal.’

Concerns and recipient responses

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

Concerns raised2

Failure of healthcare staff to fully participate in suicide and self-harm risk assessment for new prisoners
Part of recurring concern: Ineffective prison suicide and self-harm prevention systems Part of recurring concern: Unreliable ACCT suicide and self-harm prevention processes Part of recurring concern: Unreliable assessment of suicide and self-harm risk
Failure to identify or properly assess suicide and self-harm risk in newly arrived prisoners
Part of recurring concern: Ineffective prison suicide and self-harm prevention systems Part of recurring concern: Unreliable assessment of suicide and self-harm risk

Responses linked to these concerns

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

Actions described in response 13

Action
Develop and complete Trust-wide e-learning on assessing and managing self-harm and suicide risk for HMP Woodhill staff.
Stated by Central and North West London NHS Foundation TrustStated in progress
Action
Audit and continue monitoring record-keeping for staff attending ACCT reviews to ensure risk information is recorded and shared.
Stated by Central and North West London NHS Foundation TrustStated completed
Action
Introduce a next-day secondary health screen for self-harm risk after the initial reception assessment.
Stated by Central and North West London NHS Foundation TrustStated completed

Action
Strengthen the reception screening tool with detailed mental-health, self-harm and suicide-risk questions.
Stated by Central and North West London NHS Foundation TrustStated completed
Action
Train reception-screening staff, including agency staff where used, to apply the strengthened screening tool.
Stated by Central and North West London NHS Foundation TrustStated in progress
Action
Increase experienced mental-health nursing capacity in the First Night Centre to support risk assessment and management.
Stated by Central and North West London NHS Foundation TrustStated completed
Action
Check daily information-sharing and review ACCT records at each planned review meeting.
Stated by Central and North West London NHS Foundation TrustStated completed
Action
Provide daily Mental Health team risk assessments for prisoners arriving at the First Night Centre.
Stated by Central and North West London NHS Foundation TrustStated completed
Action
Provide ongoing support for prison ACCT training and prison-led ACCT management.
Stated by Central and North West London NHS Foundation TrustStated in progress
Action
Conduct an independent review of healthcare services, including mental health and substance misuse provision, alongside the safer custody review.
Stated by HM Prison and Probation ServiceStated in progress
Action
Conduct a comprehensive independent review of safer custody procedures and prison-wide factors affecting prisoner wellbeing.
Stated by HM Prison and Probation ServiceStated in progress
Action
Maintain a dedicated mental health team member on the First Night Centre to interview new prisoners and update identified risk factors.
Stated by HM Prison and Probation ServiceStated completed
Action
Implement the Entry to Custody Risk Assessment process through staged reception and first-night screening, including multi-agency review and incorporation into local policy.
Stated by HM Prison and Probation ServiceStated in progress

Respondent positions 3

Position
NOMS holds policy responsibility for suicide prevention and self-harm management.
Stated by Central and North West London NHS Foundation TrustRedirects responsibility

Other statements in published responses

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

Recipient-stated actions 7

1
Bring specialist expertise from other prison services into HMP Woodhill to support safety improvements.
Stated by Central and North West London NHS Foundation TrustStated completed
2
Amend the Mental Health referral process, including electronic referral alerts and weekly multidisciplinary review.
Stated by Central and North West London NHS Foundation TrustStated completed
3
Increase the Mental Health team to four Care Co-ordinators.
Stated by Central and North West London NHS Foundation TrustStated completed
4
Complete an independent review of healthcare provision and recent custody deaths at HMP Woodhill.
Stated by Central and North West London NHS Foundation TrustStated completed
5
Communicate review findings to relevant service providers and consult with them to agree approaches for remedying weaknesses and improving services.
Stated by HM Prison and Probation ServiceStated planned
6
Implement the Record, Respond and Reduce violence-reduction initiative as a performance measure.
Stated by HM Prison and Probation ServiceStated completed
7
Provide the coroner with updates on future developments resulting from the reviews.
Stated by HM Prison and Probation ServiceStated planned

Recipient positions 2

1
Completion of the Mental Health Assessment Unit depends on NHS England approving funding.
Stated by Central and North West London NHS Foundation TrustUnable to act
2
The healthcare provider is responsible for undertaking the review of healthcare services.
Stated by HM Prison and Probation ServiceRedirects responsibility

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

Published report and response evidence

Recipients and published responses

Report evidence summary

Concerns raised2

Failure of healthcare staff to fully participate in suicide and self-harm risk assessment for new prisoners

Failure to identify or properly assess suicide and self-harm risk in newly arrived prisoners

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.13

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

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.7

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.2

Actions described in response 13

Respondent positions 3

Recipient-stated actions 7

Recipient positions 2