PFD report

Robert Anthony Brown · Prevention of Future Deaths report

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Issued 9 Mar 2020•Staffordshire South

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
1

Of 1 recipient

Stated actions
3

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 make significant relevant prisoner information available to all staff
    Part of recurring concern: Unreliable sharing of safety-critical risk information within prisons
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

    Implement phase-three interoperability to share risk information between NOMIS and SystmOne.

    Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 27 March 2020.
  2. Action

    Automate patient administration data transfer from NOMIS to SystmOne through phase-one interoperability development.

    Stated by HM Prison and Probation ServiceStatus at responseThe respondent said that this action was partly complete when they made their response on 27 March 2020.
  3. Action

    Operate the Safer Custody Zone to enable prison, mental health and substance misuse staff to collaborate and routinely share key information.

    Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 27 March 2020.

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

  1. Position

    Further information-sharing project work is temporarily halted because the supplier was directed to prioritise COVID-19-related work.

    Stated by HM Prison and Probation ServiceUnable to actThe respondent said that a constraint prevented them from taking the relevant 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

Failure to make significant relevant prisoner information available to all staff

Wider context from the report

“Although there was no finding by the Jury that this was causative in respect of the death at times during the inquest it appeared that information in the central NOMIS records, information in the medical System 1 records and information available to the security department at the prison was not available to all staff at the prison who may have benefitted from having it. I did hear helpful evidence from the Head of Safer Custody ████████ that nationally efforts are being made to develop a system whereby significant relevant information about a prisoner is available to all staff. There is however no timescale for this. It strikes me that this would be very helpful and might prevent deaths in the future. I wonder if you can give me a progress report about this planned development and an indication as to when it might be implemented. ”

Is this part of a recurring concern?

Yes — Unreliable sharing of safety-critical risk information within prisons.

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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

Implement phase-three interoperability to share risk information between NOMIS and SystmOne.

Verbatim wording from the response

“As you know, the commissioning of healthcare in English prisons is the responsibility of NHS England and NHS Improvement, and they are leading on work with HMPPS to implement inter-operability between SystmOne and NOMIS, in order to enable better sharing of information between prison and healthcare staff. This is a big project and there are three phases of implementation. Approximately fifty percent of the planned development work on phase one, which is automating patient administration data sent from NOMIS to SystmOne, has been completed.”

Source location

2020-0065-Response-from-the-Director-General-of-Prisons
Page 1 · response
Published 27 March 2020

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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

Automate patient administration data transfer from NOMIS to SystmOne through phase-one interoperability development.

Verbatim wording from the response

“As you know, the commissioning of healthcare in English prisons is the responsibility of NHS England and NHS Improvement, and they are leading on work with HMPPS to implement inter-operability between SystmOne and NOMIS, in order to enable better sharing of information between prison and healthcare staff. This is a big project and there are three phases of implementation. Approximately fifty percent of the planned development work on phase one, which is automating patient administration data sent from NOMIS to SystmOne, has been completed.”

Source location

2020-0065-Response-from-the-Director-General-of-Prisons
Page 1 · response
Published 27 March 2020

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

Operate the Safer Custody Zone to enable prison, mental health and substance misuse staff to collaborate and routinely share key information.

Verbatim wording from the response

“While this IT project is underway, and forms an important part of the solution to the challenges presented by the information sharing in the prison environment, work is also being done at a local level to ensure that prison staff and NHS staff work together more effectively. At Dovegate, the Safer Custody Zone was formed in 2019 to provide an area in which prison staff, the Mental Health Team and the Integrated Substance Misuse Team are able to work together each day to ensure that key information is routinely shared. The introduction of the new system will further enhance this collaborative work and will enable information to be readily accessible to all staff.”

Source location

2020-0065-Response-from-the-Director-General-of-Prisons
Page 2 · response
Published 27 March 2020

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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

Further information-sharing project work is temporarily halted because the supplier was directed to prioritise COVID-19-related work.

Verbatim wording from the response

“Unfortunately, further work on this initiative has been temporarily halted by Total Phoenix Partnership (TPP), the supplier responsible for SystmOne, who have been directed to focus on COVID-19 related work. This will cause a delay, currently estimated at 8 weeks, meaning delivery of the completed phase one work is now forecast for August 2020. The sharing of risk information between NOMIS and SystmOne will form part of phase three of the project implementation, and it is forecast to be completed in 2021. If you would like any further information or updates on the project, then I would suggest contacting NHS England and NHS Improvement, as they are the lead organisation for the implementation process.”

Source location

2020-0065-Response-from-the-Director-General-of-Prisons
Page 1 · response
Published 27 March 2020

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

NHS England and NHS Improvement lead implementation of the information-sharing project and should provide further updates.

Verbatim wording from the response

“As you know, the commissioning of healthcare in English prisons is the responsibility of NHS England and NHS Improvement, and they are leading on work with HMPPS to implement inter-operability between SystmOne and NOMIS, in order to enable better sharing of information between prison and healthcare staff. This is a big project and there are three phases of implementation. Approximately fifty percent of the planned development work on phase one, which is automating patient administration data sent from NOMIS to SystmOne, has been completed.”

Source location

2020-0065-Response-from-the-Director-General-of-Prisons
Page 1 · response
Published 27 March 2020

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