PFD report

Amarjit SINGH · Prevention of Future Deaths report

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Issued 18 Sep 2023•Inner North London

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
5

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

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 raised5

  1. Careless completion of cell sharing risk assessments
    Part of recurring concern: Unsafe cell-sharing decisions for prisoners
  2. Lack of seizure-response training for prison staff
    Part of recurring concern: Inadequate prison staff training for responding to medical emergenciesPart of recurring concern: Unreliable seizure care and management
  3. Unavailability of guidance for prisoners responding to a cellmate’s fit
    Part of recurring concern: Unreliable seizure care and management
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.6

  1. Action

    Publish, introduce and circulate the national First Aid and Emergency Aid Manual to prison staff at HMP Pentonville.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 22 September 2023.
  2. Action

    Schedule training for prison staff at HMP Pentonville on responding to fits.

    Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 22 September 2023.
  3. Action

    Distribute emergency response pocket cards to prisons and staff as reminders of how to respond to medical emergencies.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 22 September 2023.

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

  1. Position

    Prison authorities, rather than healthcare, are responsible for addressing staff training and prisoner guidance on managing seizures and first aid.

    Stated by Practice Plus GroupRedirects 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

Careless completion of cell sharing risk assessments

Wider context from the report

“1. The completion of the cell sharing risk assessment was described by the extremely experienced nurse who completed it, as careless. ”

Is this part of a recurring concern?

Yes — Unsafe cell-sharing decisions for prisoners.

Open source report

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 seizure-response training for prison staff

Wider context from the report

“2. Though I was told that training for prison staff in how to deal with fits is to be given at HMP Pentonville in October 2023, I heard that there is only a hope that prisoners will also receive some guidance in what to do if their cellmate suffers a fit. Apparently, this has already been implemented in HMP Brixton. ”

Is this part of a recurring concern?

Yes — Inadequate prison staff training for responding to medical emergencies; Unreliable seizure care and management.

Open source report

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

Unavailability of guidance for prisoners responding to a cellmate’s fit

Wider context from the report

“2. Though I was told that training for prison staff in how to deal with fits is to be given at HMP Pentonville in October 2023, I heard that there is only a hope that prisoners will also receive some guidance in what to do if their cellmate suffers a fit. Apparently, this has already been implemented in HMP Brixton. ”

Is this part of a recurring concern?

Yes — Unreliable seizure care and management.

Open source report

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 ongoing first aid training for prison officers

Wider context from the report

“3. Whilst the fact that not all prison officers receive ongoing first aid training is a national resourcing issue, the level of first aid understanding of some prison officers at HMP Pentonville seemed surprisingly low. One officer told me that it did not cross his mind to start CPR in the three minutes it took nurses to arrive after Mr Singh was found not breathing. (Mr Singh had been assessed by a custodial manager as having died, but the other officer did not know this at the time.) A different officer told me he did not know that there is a difference between a person who is unconscious and a person who is dead. ”

Is this part of a recurring concern?

Yes — Inadequate prison staff training for responding to medical emergencies; Inadequate staff competence to provide first aid.

Open source report

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

Low first aid understanding among prison officers

Wider context from the report

“3. Whilst the fact that not all prison officers receive ongoing first aid training is a national resourcing issue, the level of first aid understanding of some prison officers at HMP Pentonville seemed surprisingly low. One officer told me that it did not cross his mind to start CPR in the three minutes it took nurses to arrive after Mr Singh was found not breathing. (Mr Singh had been assessed by a custodial manager as having died, but the other officer did not know this at the time.) A different officer told me he did not know that there is a difference between a person who is unconscious and a person who is dead. ”

Is this part of a recurring concern?

Yes — Inadequate staff competence to provide first aid.

Open source report

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, introduce and circulate the national First Aid and Emergency Aid Manual to prison staff at HMP Pentonville.

Verbatim wording from the response

“The HMPPS National Health and Safety Arrangements for First Aid and Emergency Aid Manual was published and introduced in August 2023 and this was circulated to all prison staff at HMP Pentonville.”

Source location

Response from HM Prison and Probation Service
Page 2 · response
Published 22 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

Schedule training for prison staff at HMP Pentonville on responding to fits.

Verbatim wording from the response

“Training for prison staff in how to deal with fits is scheduled to be given at HMP Pentonville in October, and prisoners are given instructions at their induction on how to report concerns regarding a cellmate and the need to ring the emergency cell bell in circumstances where their cellmate is unwell so that staff can ensure healthcare attend.”

Source location

Response from HM Prison and Probation Service
Page 2 · response
Published 22 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

Distribute emergency response pocket cards to prisons and staff as reminders of how to respond to medical emergencies.

Verbatim wording from the response

“should be called. In 2021, all Prisons were also issued with a supply of emergency response pocket cards which were shared with staff. The cards provided an instant reminder of how to respond to a medical emergency. In March 2022, a further supply of the emergency response pocket cards were issued to Regional Group Safety Leads for them to share with their prisons.”

Source location

Response from HM Prison and Probation Service
Page 2 · response
Published 22 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

Issue emergency response guides to all prisons, covering required actions and circumstances for calling a medical emergency response code.

Verbatim wording from the response

“At a national level, new emergency response guides were issued to all prisons which set out the actions required of staff in a medical emergency, including all the circumstances listed in the PSI 03/2013 Medical Emergency Response Codes under which a medical emergency response code”

Source location

Response from HM Prison and Probation Service
Page 1 · response
Published 22 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 the Early Days quality-assurance process, including passport checks, multidisciplinary review, task tracking and completion sign-off before patients leave the system.

Verbatim wording from the response

“Q: What strikes me is if that happened on that day, what is happening with all the other prisoners? A: Since then [AS’s death] changes have been made to the reception process, on each side. There has been a big focus on early days in custody, recognising that the first 14 days and particularly the first couple of days are the most important period in someone’s stay in prison. One of things that would identify poor completion of cell sharing risk assessment is early day passport. This is overseen by custodial managers and nursing staff. There is a checklist to ensure that everything mandatory within the process has been completed and completed to a good standard. Definitely if not completed to good standard would expect that to be flagged to me. Q: Who is doing this? A: Custodial managers.”

Source location

Response from Practice Plus Group
Page 3 · response
Published 22 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

Provide specialised reception-process training, induction explanation, shadowing and periodic refresher training for nurses completing cell-sharing risk assessments.

Verbatim wording from the response

“designed training specifically just for the reception process, which is a two day training. Which Antonio has been on recently.”

Source location

Response from Practice Plus Group
Page 3 · response
Published 22 September 2023

Open published response

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

Prison authorities, rather than healthcare, are responsible for addressing staff training and prisoner guidance on managing seizures and first aid.

Verbatim wording from the response

“Only number 1 above relates to healthcare, and therefore PPG, so we do not propose to respond to points 2 and 3, which no doubt will be addressed by the Prison.”

Source location

Response from Practice Plus Group
Page 2 · response
Published 22 September 2023

Open published response

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 reception training, Early Days checks, clinical reviews and monitoring are considered sufficient to prevent inaccurate cell-sharing risk assessments.

Verbatim wording from the response

“• Every patient has an Early Days passport as part of the Early Days process, which requires custodial managers and nurses to check off that items like the risk assessment form had been completed and completed to a sufficient standard. This requires a nurse to ensure that the risk assessment has been correctly completed, and sign off the passport.”

Source location

Response from Practice Plus Group
Page 4 · response
Published 22 September 2023

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.4

  1. 1

    Share the inquest findings with the national Safety team for consideration during future national policy review and revision.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 22 September 2023.
  2. 2

    Share lessons learned from the inquest across Practice Plus Group services.

    Stated by Practice Plus GroupStated plannedThe respondent said that this action was planned when they made their response on 22 September 2023.
  3. 3

    Provide prison teams with lists of patients with epilepsy or seizures to help custodial staff identify cell-sharing risks.

    Stated by Practice Plus GroupStated completedThe respondent said that this action was complete when they made their response on 22 September 2023.
  4. 4

    Remodel healthcare services across London with a dedicated Early Days in Custody focus intended to reduce deaths in custody.

    Stated by Practice Plus GroupStated completedThe respondent said that this action was complete when they made their response on 22 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

Share the inquest findings with the national Safety team for consideration during future national policy review and revision.

Verbatim wording from the response

“The findings of this inquest have also been shared with the national Safety team so that further consideration can be given to the points you have identified when national policy is next reviewed and revised.”

Source location

Response from HM Prison and Probation Service
Page 2 · response
Published 22 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

Share lessons learned from the inquest across Practice Plus Group services.

Verbatim wording from the response

“Practice Plus Group is committed to ensuring the high quality provision of healthcare services to all prisoners at HMP Pentonville. We will also ensure that the lessons learnt as a result of this inquest are shared across all of Practice Plus Group’s services.”

Source location

Response from Practice Plus Group
Page 5 · response
Published 22 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

Provide prison teams with lists of patients with epilepsy or seizures to help custodial staff identify cell-sharing risks.

Verbatim wording from the response

“Finally, we provide the HMP Pentonville prison team with a list of patients with epilepsy/seizures to ensure that custodial staff are also able to identify cell-sharing issues. This list is provided to all governors and custodial managers working in the establishment. We also have the Safety Intervention Meeting (SIM) and prison safety meeting where these issues can be discussed. If we wish to have an impromptu MDT (Multi-Disciplinary Team meeting) with the prison in regards to a patient then we will arrange this directly with wing managers and governors and any other relevant stakeholders.”

Source location

Response from Practice Plus Group
Page 5 · response
Published 22 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

Remodel healthcare services across London with a dedicated Early Days in Custody focus intended to reduce deaths in custody.

Verbatim wording from the response

“And nurses, with oversight, are required to complete healthcare sections Q: Do you think that such a poor standard would not exist today? A: I do Q: This was only two years ago? A: That’s one element of the changes that we have made. The other side to that is in the past year we have re-modelled healthcare across London. We have moved to new models of care. The sole purpose of new model and reason why it has been redesigned is to reduce deaths in custody. There is very much a heavy focus on early days in custody team. What is happening now is as follows. If someone comes to Pentonville this evening, they are the subject of a”

Source location

Response from Practice Plus Group
Page 3 · response
Published 22 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