PFD report

Gareth Wycliffe WARBURTON · Prevention of Future Deaths report

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Issued 4 Dec 2019•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
2

Raised in this report

Recipients
1

Named on the report

Responses found
0

Of 1 recipient

Stated actions
0

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

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Concerns raised2

  1. Failure to pass important prisoner health and welfare letters to the prison healthcare team
    Part of recurring concern: Failure to communicate clinically important information reliably between care servicesPart of recurring concern: Unreliable handling of external clinical correspondence in prisons
  2. Failure to acknowledge and answer letters containing important information about prisoners' health and welfare
    Part of recurring concern: Unreliable handling of external clinical correspondence in prisons
Responses linked to these concerns

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

No linked response statements

No respondent-stated action or position is clearly linked to these concerns.

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 pass important prisoner health and welfare letters to the prison healthcare team

Wider context from the report

“(1) Letters dated 16.10.17 and 27.11.17 from ████████ Mr. Warburton's treating clinician at the Queen Elizabeth Hospital, Birmingham to then Governor of HMP Hewell Gareth Sands, highlighting concern about the prescription error, asking for more information about the error, and seeking assurances that Mr. Warburton would continue to receive all required medication, were neither acknowledged nor answered by the Governor; (2) Furthermore, although such letters ought to have been passed on to the prison healthcare team, the evidence suggested that this was not done. Investigations carried out by current Governor Anthony Morrow failed to establish what had happened to these letters; (3) As to the suggestion that perhaps these letters were never received by the prison, it was apparent that the same letters had been sent to, and received by, members of Mr. Warburton's family; (4) Accordingly, I am satisfied that it is probable that these letters did reach the prison, but were not dealt with satisfactorily; (5) I am concerned that, as long as there is a risk that letters which seek or contain important information about a prisoner's health and welfare are not dealt with and go unanswered, there remains a risk to prisoners' lives at HMP Hewell. ”

Is this part of a recurring concern?

Yes — Failure to communicate clinically important information reliably between care services; Unreliable handling of external clinical correspondence in prisons.

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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 acknowledge and answer letters containing important information about prisoners' health and welfare

Wider context from the report

“(1) Letters dated 16.10.17 and 27.11.17 from ████████ Mr. Warburton's treating clinician at the Queen Elizabeth Hospital, Birmingham to then Governor of HMP Hewell Gareth Sands, highlighting concern about the prescription error, asking for more information about the error, and seeking assurances that Mr. Warburton would continue to receive all required medication, were neither acknowledged nor answered by the Governor; (2) Furthermore, although such letters ought to have been passed on to the prison healthcare team, the evidence suggested that this was not done. Investigations carried out by current Governor Anthony Morrow failed to establish what had happened to these letters; (3) As to the suggestion that perhaps these letters were never received by the prison, it was apparent that the same letters had been sent to, and received by, members of Mr. Warburton's family; (4) Accordingly, I am satisfied that it is probable that these letters did reach the prison, but were not dealt with satisfactorily; (5) I am concerned that, as long as there is a risk that letters which seek or contain important information about a prisoner's health and welfare are not dealt with and go unanswered, there remains a risk to prisoners' lives at HMP Hewell. ”

Is this part of a recurring concern?

Yes — Unreliable handling of external clinical correspondence in prisons.

Open source report
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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