PFD report

Bradleigh Trevor Barnes · Prevention of Future Deaths report

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Issued 24 Oct 2022•Dorset

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: 4
Responses found: 4
Stated actions: 9

Recipients and published responses

HM Prison and Probation ServiceResponse found NHS England

Response foundOxleas NHS Foundation TrustResponse found Portland Prison and Young Offender InstitutionResponse found

Source document

Full report text

This is the full text from the original published report.

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Investigation and inquest

On the 9th January 2020 an investigation was commenced into the death of Bradleigh Trevor Barnes, born on the 21st March 1996.

The investigation concluded at the end of the Inquest on the 20th October 2022.

The Medical Cause of Death was:

1a Ligature Suspension

The conclusion of the Inquest was suicide.

Coroner’s concerns

1. During the Inquest evidence was heard that:

i. In the days leading up to Bradleigh’s death he barricaded himself in his cell and force was used to remove him from the cell. PSO 1600 is a HMP Prison Service document which provides guidance to Prison staff on the use of force. Whilst it can be accessed by others outside the prison, there is no national guidance from the NHS to healthcare professionals about the use of force in prison. Lisa Turner, the Regional Healthcare Service Manager Practice Plus Group (PPG) who currently provide the healthcare at HMP YOI Portland, confirmed it would be of benefit to have such national guidance to assist the healthcare staff when force is used in prison. Healthcare input is critical in the use of force due to risks of positional asphyxia which could lead to a future death as well as the risk of injury.

ii. At section 6 of PSO 1600 it details the “Role of Healthcare in planned and unplanned use of force” and at 6.11 states that procedures should be agreed at a local level. There is no local operating policy between the prison and the healthcare at HMP YOI Portland. Oxleas NHS Foundation Trust (Oxleas) are to take over the contract for the healthcare at HMP YOI Portland on the 1st December 2022 from PPG.

iii. ████████

2. I have concerns with regard to the following:

i. There is a lack of national guidance to healthcare staff on the use of force in prison and I request consideration is given by NHS England to providing such national guidance.

ii. There is no local operating policy on the use of force at HMP YOI Portland between the healthcare and the prison and I request that the Governor of HMP YOI Portland and the Chief Executive of Oxleas consider putting a local instruction policy in place.

iii. ████████

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Concerns and recipient responses

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

Concerns raised2

Lack of national guidance for healthcare staff on the use of force in prison
Absence of a local operating policy on the use of force between prison and healthcare services
Part of recurring concern: Unsafe interoperability between prison custody and healthcare procedures

Responses linked to these concerns

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

Actions described in response 6

Action
Implement a memorandum of understanding governing healthcare attendance at, and planned participation in, use-of-force interventions.
Stated by Oxleas NHS Foundation TrustStated completed
Action
Write to prison healthcare providers requiring agreed local procedures covering healthcare roles during restraint and monitoring, recording and response to vital signs during and after incidents.
Stated by NHS EnglandStated planned
Action
Request assurance from regional commissioning directors that the required local procedures have been implemented and evidenced by April 2023.
Stated by NHS EnglandStated planned

Respondent positions 3

Position
NHS England cannot issue prison use-of-force guidance independently of the operational PSIs, PSOs and Policy Frameworks governing prisons.
Stated by NHS EnglandUnable to act

Other statements in published responses

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

Recipient-stated actions 3

1
Provide joint training for healthcare staff and prison officers on use-of-force techniques and associated medical risks.
Stated by Oxleas NHS Foundation TrustStated planned
2
Replace metal bedframes at HMP Portland with new whitewood furniture beds.
Stated by HM Prison and Probation ServiceStated completed
3
Complete a review of fire-safety requirements for furniture, mattresses and bedding in prison establishments.
Stated by HM Prison and Probation ServiceStated completed

Recipient positions 2

1
Current mattresses meet stringent fire-retardancy standards, with safety requirements explaining their hardness and limiting the case for alternatives.
Stated by HM Prison and Probation ServiceExisting arrangements considered sufficient
2
Local monitoring, challenge and removal of additional mattresses address the risk of mattresses being used as barricades.
Stated by HM Prison and Probation ServiceExisting arrangements considered sufficient

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

Lack of national guidance for healthcare staff on the use of force in prison

Absence of a local operating policy on the use of force between prison and healthcare services

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.6

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.3

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 6

Respondent positions 3

Recipient-stated actions 3

Recipient positions 2