Declan Carr · Prevention of Future Deaths report

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Issued 20 Oct 2025•East Riding and Hull

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
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
6

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 raised1

  1. Failure to ensure continuity of psycho-social drug misuse support during prisoner transfers
    Part of recurring concern: Failure to ensure safe prisoner transfers

Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.6

  1. NHS England

    Use nationally agreed clinical templates, including Court, Release and Transfer Out screening, to standardise information sharing and healthcare delivery.

  2. NHS England

    Discuss all received Reports to Prevent Future Deaths through the Regulation 28 Working Group to share learning nationally and regionally.

  3. NHS England

    Review NHS England Health and Justice service specifications using learning from this case.

  4. NHS England

    Present this case’s findings and learning for discussion at a future Health and Justice Delivery Oversight Group meeting.

  5. NHS England

    Audit continuity of care for relevant transfers between HMP Hull and HMP Humber.

  6. NHS England

    Complete a second audit against the same continuity-of-care parameters in January 2026.

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

  1. NHS England

    The existing transfer pathway was considered sufficient because it was followed correctly and referrals were opened for all transferred service users.

    Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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 ensure continuity of psycho-social drug misuse support during prisoner transfers

Wider context from the report

“Mr Carr was receiving psycho-social support regarding his substance misuse from healthcare services whilst he was in HMP Hull. He was due to have a further appointment with them on 16th August 2023. However, on this date Mr Carr was transferred to HMP Humber. HMP Humber were not made aware that Mr Carr was receiving psycho-social support and there was no handover to the support services in HMP Humber. There was then no support in place for Mr Carr. During the inquest I heard evidence that if Mr Carr had been receiving clinical support for drug misuse there would have been a handover for that to continue. I was also made aware that HMP Humber and HMP Hull now have a local policy in place to allow the prisons to share information about those that are receiving psycho-social support when transferring prisoners between these 2 prisons as they are the same agency that provide that service. However, I was informed that this a purely local arrangement and this is not a process that happens nationally and would cease if one of the prisons changed providers. If there is a lack of continuity of care for prisoners receiving psycho-social for drug misuse support then there is a risk of future deaths occurring. ”

Is this part of a recurring concern?

Yes — Failure to ensure safe prisoner transfers.

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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

Use nationally agreed clinical templates, including Court, Release and Transfer Out screening, to standardise information sharing and healthcare delivery.

Verbatim wording from the response

“There are nationally agreed clinical templates embedded on SystemOne, which is an electronic patient medical record system. One of these templates is specific to Court, Release and Transfer Out screening. A copy of the template has been attached with this response. The purpose of national agreed templates is to ensure standardised healthcare delivery aligned with National Institute for Health and Care Excellence (NICE) guidance and key performance indicators.”

Source location

Response from NHS England
Page 3 · response
Published 29 October 2025

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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

Discuss all received Reports to Prevent Future Deaths through the Regulation 28 Working Group to share learning nationally and regionally.

Verbatim wording from the response

“I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Declan, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.”

Source location

Response from NHS England
Page 4 · response
Published 29 October 2025

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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

Review NHS England Health and Justice service specifications using learning from this case.

Verbatim wording from the response

“A review of the NHS England Health and Justice service specifications is being undertaken by NHS England through 2025 to 2026, and any learning from this case will be used to inform this review.”

Source location

Response from NHS England
Page 2 · response
Published 29 October 2025

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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

Present this case’s findings and learning for discussion at a future Health and Justice Delivery Oversight Group meeting.

Verbatim wording from the response

“The findings, information and any learning from this case will also be listed for discussion at a future NHS England Health and Justice Delivery Oversight Group (HJDOG). The HJDOG is the senior leadership forum, which holds responsibility for the oversight of delivery and continuous improvement in Health and Justice commissioned services, through both national and regional teams. All health and justice related Reports to Prevent Future Deaths are shared and discussed at the HJDOG, and assurance is sought from regions where learning and action is identified.”

Source location

Response from NHS England
Page 2 · response
Published 29 October 2025

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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

Audit continuity of care for relevant transfers between HMP Hull and HMP Humber.

Verbatim wording from the response

“For assurance, an audit on the continuity of care between HMP Hull to HMP Humber for those in service with CGL not prescribed opioid substitution therapy was conducted for transfers in June 2025. This audit confirmed that:”

Source location

Response from NHS England
Page 4 · response
Published 29 October 2025

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

Complete a second audit against the same continuity-of-care parameters in January 2026.

Verbatim wording from the response

“A second audit will be completed against the same parameters in January 2026. There was no action plan attached to the audit, as the findings showed that the pathway was being followed correctly and 100% of those transferred from HMP Hull were picked up and a referral opened in HMP Humber.”

Source location

Response from NHS England
Page 4 · response
Published 29 October 2025

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

The existing transfer pathway was considered sufficient because it was followed correctly and referrals were opened for all transferred service users.

Verbatim wording from the response

“A second audit will be completed against the same parameters in January 2026. There was no action plan attached to the audit, as the findings showed that the pathway was being followed correctly and 100% of those transferred from HMP Hull were picked up and a referral opened in HMP Humber.”

Source location

Response from NHS England
Page 4 · response
Published 29 October 2025

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