PFD report

Warren Martin Sampson · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 6 Sep 2015•Essex

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.

View original report
Concerns
4

Raised in this report

Recipients
3

Named on the report

Responses found
1

Of 3 recipients

Stated actions
2

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

Open published report

Concerns and recipient responses

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

Concerns raised4

  1. Lack of a process for following up non-attendance at Reception Healthcare first night screening
    Part of recurring concern: Inadequate prison reception safeguards
  2. Lack of a system ensuring that all officers are familiar with local directives and instructions
    Part of recurring concern: Unreliable officer access to and familiarisation with required operational instructions
  3. Ad hoc attendance of representatives from all disciplines, especially Healthcare, at ACCT reviews
    Part of recurring concern: Unreliable ACCT suicide and self-harm prevention processes
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.2

  1. Action

    Undertake a second health screen within 72 hours of arrival, checking GP-record consent and recording refusals in SystmOne.

    Stated by Care UKStated completedThe respondent said that this action was complete when they made their response on 6 September 2016.
  2. Action

    Require daily email invitations to healthcare professionals for ACCT reviews and record their attendance or other input in ACCT documentation and SystmOne.

    Stated by Care UKStated completedThe respondent said that this action was complete when they made their response on 6 September 2016.

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 a process for following up non-attendance at Reception Healthcare first night screening

Wider context from the report

“(2) The lack of a process for following up non- attendance at the Reception Healthcare first night screening ”

Is this part of a recurring concern?

Yes — Inadequate prison reception safeguards.

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 a system ensuring that all officers are familiar with local directives and instructions

Wider context from the report

“(3) The lack of a system for ensuring that all officers are familiar with local directives and instructions ”

Is this part of a recurring concern?

Yes — Unreliable officer access to and familiarisation with required operational instructions.

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

Ad hoc attendance of representatives from all disciplines, especially Healthcare, at ACCT reviews

Wider context from the report

“(1) The “ad hoc” attendance at ACCT reviews of representatives from all disciplines especially Healthcare. The lack of written evidence within the ACCT documentation of contributory input from other agencies such as Healthcare. ”

Is this part of a recurring concern?

Yes — Unreliable ACCT suicide and self-harm prevention processes.

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 written evidence of contributory input from other agencies in ACCT documentation

Wider context from the report

“(1) The “ad hoc” attendance at ACCT reviews of representatives from all disciplines especially Healthcare. The lack of written evidence within the ACCT documentation of contributory input from other agencies such as Healthcare. ”

Is this part of a recurring concern?

Yes — Unreliable ACCT suicide and self-harm prevention processes.

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

Undertake a second health screen within 72 hours of arrival, checking GP-record consent and recording refusals in SystmOne.

Verbatim wording from the response

“The process now is that a Second Health Screen is undertaken within 72 hours of an inmate arriving at HMP Chelmsford and at that second health screen there would be a”

Source location

Response from Care UK
Page 1 · response
Published 6 September 2016

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

Require daily email invitations to healthcare professionals for ACCT reviews and record their attendance or other input in ACCT documentation and SystmOne.

Verbatim wording from the response

“It is the process now that discipline staff each day will email healthcare with the ACCT reviews they are intending to hold that day and invite the appropriate healthcare professional to input into the process, whether it be primary healthcare, mental health or a member of the substance misuse team. Attendance will be in person where possible but where a healthcare professional is unable to attend, the input of healthcare, for example, by telephone, must be recorded on the ACCT document and in SystmOne. This has been reaffirmed to healthcare staff.”

Source location

Response from Care UK
Page 1 · response
Published 6 September 2016

Open published response
Back to top

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