PFD report

John Martin Chapman · Prevention of Future Deaths report

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Issued 11 Jan 2018•Lancashire

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
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. Failure to routinely share prisoner self-harm and well-being information with reception healthcare staff
    Part of recurring concern: Inadequate prison reception safeguardsPart of recurring concern: Ineffective prison suicide and self-harm prevention systemsPart of recurring concern: Unreliable sharing of safety-critical risk information within prisonsPart 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 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

    Provide reception staff with PSI 07/2015, require them to read and comply with it, and monitor completion through performance records.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 7 March 2018.
  2. Action

    Explore incorporating a PER-form receipt check into the existing reception health-screen template.

    Stated by North Cheshire and Mersey NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 7 March 2018.
  3. Action

    Routinely pass PER forms to the reception nurse and require documentation in SystemOne that each form was received and considered.

    Stated by North Cheshire and Mersey NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 7 March 2018.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    CNomis is not managed by healthcare, and reception nurses are not routinely granted access to it.

    Stated by North Cheshire and Mersey NHS Foundation TrustOutside remitThe respondent said that this matter was outside its role or authority.

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 routinely share prisoner self-harm and well-being information with reception healthcare staff

Wider context from the report

“1. TO THE GOVERNOR HMP WYмott Although evidence was heard to the effect that currently at reception at HMP Wymott the CNomis entries relating to a newly arrived prisoner are scrutinised by prison reception staff to ascertain whether there are any self-harm or welfare alerts, it did not appear that a direction exists to pass relevant information to the nurse carrying out the reception medical screen. 2. TO THE GOVERNOR AND HEAD OF HEALTHCARE There does not appear to be a mechanism at reception whereby information relevant to the self-harm or well-being of a prisoner is routinely shared by prison staff with medical staff carrying out a reception medical screen including alerts on the CNomis system. As a result, there appears to be a danger that significant alerts concerning a prisoner might not come to the attention of the reception nurse to enable the nurse to take appropriate action and make relevant entries within the medical records. Those in authority, giving evidence on behalf of the prison and healthcare on the subject of reception practice, saw merit in there being a formal procedure agreed between prison discipline staff on the one hand and healthcare staff on the other, for the sharing of information relevant to a prisoner’s well-being, and for this to be accomplished promptly. ”

Is this part of a recurring concern?

Yes — Inadequate prison reception safeguards; Ineffective prison suicide and self-harm prevention systems; Unreliable sharing of safety-critical risk information within prisons; Unsafe interoperability between prison custody and healthcare procedures.

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

Provide reception staff with PSI 07/2015, require them to read and comply with it, and monitor completion through performance records.

Verbatim wording from the response

“Every member of staff in reception at HMP Preston has been provided with a copy of the PSI and set an objective to read and comply with it in their Staff Performance and Development Record. Line managers will monitor the achievement of this objective. Copies of the PSI are also available in the reception area.”

Source location

2018-0007-Response-by-HM-Prison-and-Probation-Service
Page 2 · response
Published 7 March 2018

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

Explore incorporating a PER-form receipt check into the existing reception health-screen template.

Verbatim wording from the response

“As you note in your report, you were advised during the inquest that the prison and healthcare intended to hold a meeting to discuss ways in which the sharing of information during the reception process might be improved. I can advise you that this meeting took place recently on March 1st. As a result of the meeting between the prison and healthcare it has been agreed that henceforth PER forms will be passed to the reception nurse as a matter of routine and the nurse must then document within the SystemOne record that the form has been received and considered. It is hoped that this “check” may be incorporated into the record system, as part of the existing reception health screen template, and this possibility is currently being explored. Thank you once again for bringing your concern to my attention.”

Source location

2018-0007-Response
Page 1 · response
Published 7 March 2018

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

Routinely pass PER forms to the reception nurse and require documentation in SystemOne that each form was received and considered.

Verbatim wording from the response

“As you note in your report, you were advised during the inquest that the prison and healthcare intended to hold a meeting to discuss ways in which the sharing of information during the reception process might be improved. I can advise you that this meeting took place recently on March 1st. As a result of the meeting between the prison and healthcare it has been agreed that henceforth PER forms will be passed to the reception nurse as a matter of routine and the nurse must then document within the SystemOne record that the form has been received and considered. It is hoped that this “check” may be incorporated into the record system, as part of the existing reception health screen template, and this possibility is currently being explored. Thank you once again for bringing your concern to my attention.”

Source location

2018-0007-Response
Page 1 · response
Published 7 March 2018

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

CNomis is not managed by healthcare, and reception nurses are not routinely granted access to it.

Verbatim wording from the response

“As a result there appears to be a danger that significant alerts concerning a prisoner might not come to the attention of the reception nurse” It is, of course, recognised that it is important to share relevant information and the reception nurse would expect prison officers always to communicate any significant information regarding risk or welfare of which they were aware – whether this be contained in a PER document, on CNomis, or otherwise. As you were made aware during the inquest, it was not the practice, at the time, for the PER document to be passed by prison officers to the reception nurse and, regards CNomis, this is not a system managed by healthcare and nurses are not routinely granted access to it.”

Source location

2018-0007-Response
Page 1 · response
Published 7 March 2018

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.7

  1. 1

    Issue resuscitation aids to all staff with prisoner contact by June.

    Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 7 March 2018.
  2. 2

    Amend contingency plans to instruct managers to provide relevant information to all staff after future deaths at HMP Preston.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 7 March 2018.
  3. 3

    Provide emergency boxes containing resuscitation aids on all residential units at HMP Preston.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 7 March 2018.
  4. 4

    Roll out revised suicide and self-harm prevention training, prioritising reception staff at HMP Preston.

    Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 7 March 2018.
  5. 5

    Review the content of HMP Preston’s local instruction on night procedures against existing national policies.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 7 March 2018.
  6. 6

    Issue national learning bulletins to raise staff awareness of risks identified from deaths in custody.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 7 March 2018.
  7. 7

    Hold a joint prison-healthcare meeting to discuss improving information sharing during reception screening.

    Stated by North Cheshire and Mersey NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 7 March 2018.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    No further action is necessary because the relevant night-time procedures are already in place across the estate through existing national policies.

    Stated by HM Prison and Probation ServiceExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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 resuscitation aids to all staff with prisoner contact by June.

Verbatim wording from the response

“Resuscitation aids Your next concern is that not all staff at Preston carry resuscitation aids. Emergency boxes containing resuscitation aids are currently available on all residential units at the Prison, and there are plans for all staff with prisoner contact to be issued with them by June this year.”

Source location

2018-0007-Response-by-HM-Prison-and-Probation-Service
Page 2 · response
Published 7 March 2018

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

Amend contingency plans to instruct managers to provide relevant information to all staff after future deaths at HMP Preston.

Verbatim wording from the response

“Sharing learning from deaths in custody Your third concern is that staff at HMP Preston are not notified about the manner of each non-natural death that occurs. The establishment’s contingency plans have been amended to instruct managers to provide relevant information to all staff in the event of future deaths at the prison.”

Source location

2018-0007-Response-by-HM-Prison-and-Probation-Service
Page 2 · response
Published 7 March 2018

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 emergency boxes containing resuscitation aids on all residential units at HMP Preston.

Verbatim wording from the response

“Resuscitation aids Your next concern is that not all staff at Preston carry resuscitation aids. Emergency boxes containing resuscitation aids are currently available on all residential units at the Prison, and there are plans for all staff with prisoner contact to be issued with them by June this year.”

Source location

2018-0007-Response-by-HM-Prison-and-Probation-Service
Page 2 · response
Published 7 March 2018

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

Roll out revised suicide and self-harm prevention training, prioritising reception staff at HMP Preston.

Verbatim wording from the response

“You may also wish to be aware that we have introduced revised suicide and self-harm prevention training for all staff in HMPPS, and that at Preston staff working in reception are being given priority as this is rolled out.”

Source location

2018-0007-Response-by-HM-Prison-and-Probation-Service
Page 2 · response
Published 7 March 2018

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 the content of HMP Preston’s local instruction on night procedures against existing national policies.

Verbatim wording from the response

“National instructions on procedures at night Finally, you suggest that an instruction issued at HMP Preston about procedures at night could be issued nationally. We have reviewed the content of this local instruction, and found that it has been drawn from existing national policies, including PSI 64/2011 Safer Custody, PSI 24/2011 Management and Security of Nights and PSI 63/2011 Management of the Local Security Strategy. As a result I am satisfied that no further action is necessary, as the relevant instructions are already in place across the estate.”

Source location

2018-0007-Response-by-HM-Prison-and-Probation-Service
Page 2 · response
Published 7 March 2018

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 national learning bulletins to raise staff awareness of risks identified from deaths in custody.

Verbatim wording from the response

“We are committed to sharing learning from the circumstances of deaths as widely as possible across the estate; indeed, we frequently issue national learning bulletins to raise staff awareness of risks identified from them.”

Source location

2018-0007-Response-by-HM-Prison-and-Probation-Service
Page 2 · response
Published 7 March 2018

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 a joint prison-healthcare meeting to discuss improving information sharing during reception screening.

Verbatim wording from the response

“As you note in your report, you were advised during the inquest that the prison and healthcare intended to hold a meeting to discuss ways in which the sharing of information during the reception process might be improved. I can advise you that this meeting took place recently on March 1st. As a result of the meeting between the prison and healthcare it has been agreed that henceforth PER forms will be passed to the reception nurse as a matter of routine and the nurse must then document within the SystemOne record that the form has been received and considered. It is hoped that this “check” may be incorporated into the record system, as part of the existing reception health screen template, and this possibility is currently being explored. Thank you once again for bringing your concern to my attention.”

Source location

2018-0007-Response
Page 1 · response
Published 7 March 2018

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

No further action is necessary because the relevant night-time procedures are already in place across the estate through existing national policies.

Verbatim wording from the response

“National instructions on procedures at night Finally, you suggest that an instruction issued at HMP Preston about procedures at night could be issued nationally. We have reviewed the content of this local instruction, and found that it has been drawn from existing national policies, including PSI 64/2011 Safer Custody, PSI 24/2011 Management and Security of Nights and PSI 63/2011 Management of the Local Security Strategy. As a result I am satisfied that no further action is necessary, as the relevant instructions are already in place across the estate.”

Source location

2018-0007-Response-by-HM-Prison-and-Probation-Service
Page 2 · response
Published 7 March 2018

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