Anthony Paine · Prevention of Future Deaths report

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Issued 28 Mar 2018•Liverpool and the Wirral

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an evidence connection; it does not assign responsibility.

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Concerns
0

Raised in this report

Recipients
4

Named on the report

Responses found
2

Of 4 recipients

Stated actions
13

Described in responses

Recipients and published responses

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 raised0

    Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.13

    1. Ministry of Justice

      Share learning from the incident widely across the prison estate.

    2. Ministry of Justice

      Ensure prison healthcare provision is equal to community healthcare provision.

    3. Ministry of Justice

      Continue collaborative work to reduce self-harm and self-inflicted deaths in prisons.

    4. Ministry of Justice

      Transfer HMP Liverpool healthcare provision to Spectrum Community Health in partnership with Mersey Care NHS Foundation Trust.

    5. NHS England

      Transitioned HMP Liverpool healthcare provision to Spectrum, with mental healthcare subcontracted to Mersey Care.

    6. NHS England

      Share the independent investigation report with national nursing and quality leads, agree national learning actions and implement them.

    7. NHS England

      Continue managing recommendations from custody-death reviews and Prevention of Future Deaths reports within the quality framework and sharing learning across organisations.

    8. NHS England

      Oversee provider transition through a multi-agency project board with monthly patient-safety monitoring and quarterly quality-framework reviews.

    9. NHS England

      Implement the revised National Partnership Agreement to strengthen multi-agency approaches, shared accountability and learning to reduce self-harm and self-inflicted deaths.

    10. NHS England

      Review fatal incidents and work with Spectrum to ensure learning informs health services and remedial action plans.

    11. NHS England

      Develop a comprehensive ten-point plan for coherent, timely and appropriate transfers and remissions of prisoners under the Mental Health Act.

    12. NHS England

      Conduct clinical quality visits to verify implementation of death-review recommendations and identify changes in policies, practice and service delivery.

    13. NHS England

      Refresh and publish the mental-health service specification to support adaptation to individual prison populations.

    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 learning from the incident widely across the prison estate.

    Verbatim wording from the response

    “Thank you again for bringing these matters of concern to my attention. We will ensure that learning from this tragic incident is shared widely across the prison estate.”

    Source location

    2018-0088-Response-by-HM-Prison-Probation-Service
    Page 2 · response
    Published 16 June 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

    Ensure prison healthcare provision is equal to community healthcare provision.

    Verbatim wording from the response

    “committed to ensuring that healthcare provision in prisons is equal to that delivered in the community. The National Partnership Agreement in place with NHS England, considers the reduction of incidents of self-harm and self-inflicted deaths to be a priority and we continue to work collaboratively to make improvements in this area.”

    Source location

    2018-0088-Response-by-HM-Prison-Probation-Service
    Page 2 · response
    Published 16 June 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

    Continue collaborative work to reduce self-harm and self-inflicted deaths in prisons.

    Verbatim wording from the response

    “committed to ensuring that healthcare provision in prisons is equal to that delivered in the community. The National Partnership Agreement in place with NHS England, considers the reduction of incidents of self-harm and self-inflicted deaths to be a priority and we continue to work collaboratively to make improvements in this area.”

    Source location

    2018-0088-Response-by-HM-Prison-Probation-Service
    Page 2 · response
    Published 16 June 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

    Transfer HMP Liverpool healthcare provision to Spectrum Community Health in partnership with Mersey Care NHS Foundation Trust.

    Verbatim wording from the response

    “From 1 April 2018 responsibility for the healthcare provision at HMP Liverpool passed from Lancashire Care NHS Foundation Trust to a new provider, Spectrum Community Health CiC (Spectrum), in partnership with Mersey Care NHS Foundation Trust, who are current providers of mental health community services in Liverpool. This will provide a consistent approach to the continuity of care for people within the criminal justice system. Spectrum currently provide healthcare across six prisons in the North of England.”

    Source location

    2018-0088-Response-by-HM-Prison-Probation-Service
    Page 2 · response
    Published 16 June 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

    Transitioned HMP Liverpool healthcare provision to Spectrum, with mental healthcare subcontracted to Mersey Care.

    Verbatim wording from the response

    “The provider of healthcare services in HMP Liverpool at the time of the incident was Lancashire Care NHS Foundation Trust (“LCFT”) who served notice on their contract and are no longer providing services in HMP Liverpool with effect from 31st March 2018.”

    Source location

    2018-0088-Response-by-NHS-England
    Page 1 · response
    Published 16 June 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

    Share the independent investigation report with national nursing and quality leads, agree national learning actions and implement them.

    Verbatim wording from the response

    “The NHS England Health and Justice Nursing and Quality Leads meet on a quarterly basis and review the learnings from deaths in custody reports. Once the independent investigation has been concluded into this death the report will be shared at the next meeting, following the report and action for national learning will be agreed and implemented. There are also opportunities within NHS England to share the learning from this report with other healthcare commissioners.”

    Source location

    2018-0088-Response-by-NHS-England
    Page 2 · response
    Published 16 June 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

    Continue managing recommendations from custody-death reviews and Prevention of Future Deaths reports within the quality framework and sharing learning across organisations.

    Verbatim wording from the response

    “NHS England (North) currently have a multi-agency project board in place to oversee the smooth transition of change of the healthcare provider. Patient safety is a core feature of the project plan, which is monitored monthly by the project board. In addition, patient safety is embedded in the quality framework, which is reviewed and monitored quarterly as part of the quarterly contract review process, supported by quality assurance visits of the healthcare provision. The management of recommendations from previous death in custody reviews and Regulation 28 Prevent Future Death Reports will continue to be managed within the quality framework with the new provider, ensuring that they are accountable for the safety of patients within their care, and that learning from previous deaths is shared across the organisations.”

    Source location

    2018-0088-Response-by-NHS-England
    Page 2 · response
    Published 16 June 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

    Oversee provider transition through a multi-agency project board with monthly patient-safety monitoring and quarterly quality-framework reviews.

    Verbatim wording from the response

    “NHS England (North) currently have a multi-agency project board in place to oversee the smooth transition of change of the healthcare provider. Patient safety is a core feature of the project plan, which is monitored monthly by the project board. In addition, patient safety is embedded in the quality framework, which is reviewed and monitored quarterly as part of the quarterly contract review process, supported by quality assurance visits of the healthcare provision. The management of recommendations from previous death in custody reviews and Regulation 28 Prevent Future Death Reports will continue to be managed within the quality framework with the new provider, ensuring that they are accountable for the safety of patients within their care, and that learning from previous deaths is shared across the organisations.”

    Source location

    2018-0088-Response-by-NHS-England
    Page 2 · response
    Published 16 June 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

    Implement the revised National Partnership Agreement to strengthen multi-agency approaches, shared accountability and learning to reduce self-harm and self-inflicted deaths.

    Verbatim wording from the response

    “Nationally NHS England and its partners Ministry of Justice (“MoJ”), HMPPS, Public Health England (“PHE”) and the Department of Health and Social Care (“DHSC”) have signed up to a revised National Partnership Agreement¹ (NPA) covering 2018 – 2021 for healthcare services in prisons. The partnership agreement on prison healthcare has been in place since 2013 and supports the commissioning and delivery of healthcare in English prisons. The revised NPA sets out our commitment to working together and sharing accountability for delivery through linked governance structures and core objectives and priorities for 2018 – 2021. Priority one is to continue to work collaboratively to improve”

    Source location

    2018-0088-Response-by-NHS-England
    Page 2 · response
    Published 16 June 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 fatal incidents and work with Spectrum to ensure learning informs health services and remedial action plans.

    Verbatim wording from the response

    “NHS England (North) has reviewed the fatal incidents that have occurred in HMP Liverpool over the previous two years and are currently working with the new provider Spectrum to ensure that learning for health is evident from these deaths. The remedial action plans for previous deaths in custody are reviewed and managed as part of the quarterly contract review meetings. In the previous two years there have been twelve deaths in HMP Liverpool of which six have been considered as self-inflicted. Each death is regrettable and NHS England acknowledges are also potentially preventable.”

    Source location

    2018-0088-Response-by-NHS-England
    Page 2 · response
    Published 16 June 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

    Develop a comprehensive ten-point plan for coherent, timely and appropriate transfers and remissions of prisoners under the Mental Health Act.

    Verbatim wording from the response

    “In addition to the work NHS England is undertaking in partnership with HMPPS and PHE to improve and redesign services for people in prison with mental health needs we are revising the approaches to secure hospital transfers ensuring when a person needs to be in a hospital setting for their mental health needs this is done in a coherent, timely and appropriate manner. As part of this, a comprehensive ten-point plan “Right Care, Right Place, Right Time” for the transfer and remission of prisoners under the Mental Health Act is being developed.”

    Source location

    2018-0088-Response-by-NHS-England
    Page 3 · response
    Published 16 June 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

    Conduct clinical quality visits to verify implementation of death-review recommendations and identify changes in policies, practice and service delivery.

    Verbatim wording from the response

    “In addition to the above, NHS England (North) has regular clinical quality visits which supports health commissioners to obtain assurance that all the recommendations from action plans have been adhered to and that, where required, practice has changed or improved. This will be evidenced by reviewing policies, procedures, reviewing practice and service delivery.”

    Source location

    2018-0088-Response-by-NHS-England
    Page 2 · response
    Published 16 June 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

    Refresh and publish the mental-health service specification to support adaptation to individual prison populations.

    Verbatim wording from the response

    “Nationally NHS England is completing a programme of work to refresh all health and justice service specification, which the regional health commissioners procure services against. The mental health service specification refresh has been completed and published in March 2018. This refresh entailed redesigning the structure of the specifications to allow them to be more easily adapted to the defined needs of the individual prison population. The new provider, Spectrum has reviewed the new specifications and are currently benchmarking against them as part of the new model development work ongoing with partners at HMP Liverpool. We anticipate that this work will be completed by the end of June 2018.”

    Source location

    2018-0088-Response-by-NHS-England
    Page 3 · response
    Published 16 June 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