PFD report

Marlin Burrows · Prevention of Future Deaths report

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Issued 30 Apr 2024•Liverpool and the Wirral

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
1

Named on the report

Responses found
2

Of 1 recipient

Stated actions
13

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 raised4

  1. Lack of clarity about the welfare sheet’s purpose for monitoring prisoners whose health is of concern
    Part of recurring concern: Inadequate supervision and monitoring of prisonersPart of recurring concern: Unreliable welfare-check processes for people whose health is of concern
  2. Insufficient guidance for completing the welfare sheet
  3. Failure of prison and healthcare services to jointly consider the welfare sheet’s nature and operation
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.8

  1. Action

    Work with HMP Garth healthcare staff to develop training and awareness sessions for prison staff on welfare checklist use and guidance.

    Stated by Greater Manchester Mental Health NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 9 May 2024.
  2. Action

    Complete monthly assurance checks cross-referencing welfare checklist signatures with clinical records.

    Stated by Greater Manchester Mental Health NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 9 May 2024.
  3. Action

    Instruct attending healthcare staff to obtain, review and understand welfare checklist entries before clinical assessment.

    Stated by Greater Manchester Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 May 2024.

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

  1. Position

    HMPPS is developing national guidance addressing welfare checklist concerns about purpose, completion guidance and joint consideration.

    Stated by Greater Manchester Mental Health NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking 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

Lack of clarity about the welfare sheet’s purpose for monitoring prisoners whose health is of concern

Wider context from the report

“(1) The existing welfare sheet lacks clarity as to its exact purpose in terms of monitoring a prisoner whose health is of concern. ”

Is this part of a recurring concern?

Yes — Inadequate supervision and monitoring of prisoners; Unreliable welfare-check processes for people whose health is of concern.

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

Insufficient guidance for completing the welfare sheet

Wider context from the report

“(2) The sheet contains little guidance in relation to its completion. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Failure of prison and healthcare services to jointly consider the welfare sheet’s nature and operation

Wider context from the report

“(4) The nature and operation of the sheet appears not to have been the subject of joint consideration on behalf of both prison and healthcare ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Failure to communicate prison staff entries on the welfare sheet to attending medical staff

Wider context from the report

“(3) Entries on the sheet made by prison staff appear not to be made known to attending medical staff ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Work with HMP Garth healthcare staff to develop training and awareness sessions for prison staff on welfare checklist use and guidance.

Verbatim wording from the response

“In addition, the Head of Nursing and Quality for the Health & Justice Division at GMMH will work with the Healthcare staff at HMP Garth to develop some training and awareness sessions for prison staff around the use of the welfare checklist and the associated guidance once the national policy is implemented.”

Source location

Response from Greater Manchester Mental Health
Page 2 · response
Published 9 May 2024

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 monthly assurance checks cross-referencing welfare checklist signatures with clinical records.

Verbatim wording from the response

“All Healthcare staff attending prisoners have been informed that they must request the welfare checklist document on arrival at the wing, ensuring they have read and understood the entries to inform clinical decision making. This will be evidenced by them signing the sheet to say they have reviewed the information and their entry in the clinical record will state they have reviewed the welfare checklist and communicated with prison staff as part of their clinical assessment. In addition to this, assurance checks will be completed monthly by the Primary Care Manager who will review the welfare check sheets ensuring the attending staff have reviewed and signed the sheets as part of their assessment. This will be cross referenced with the clinical record to ensure that this information was considered when undertaking the assessment.”

Source location

Response from Greater Manchester Mental Health
Page 2 · response
Published 9 May 2024

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

Instruct attending healthcare staff to obtain, review and understand welfare checklist entries before clinical assessment.

Verbatim wording from the response

“All Healthcare staff attending prisoners have been informed that they must request the welfare checklist document on arrival at the wing, ensuring they have read and understood the entries to inform clinical decision making. This will be evidenced by them signing the sheet to say they have reviewed the information and their entry in the clinical record will state they have reviewed the welfare checklist and communicated with prison staff as part of their clinical assessment. In addition to this, assurance checks will be completed monthly by the Primary Care Manager who will review the welfare check sheets ensuring the attending staff have reviewed and signed the sheets as part of their assessment. This will be cross referenced with the clinical record to ensure that this information was considered when undertaking the assessment.”

Source location

Response from Greater Manchester Mental Health
Page 2 · response
Published 9 May 2024

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 healthcare staff to record welfare checklist review and communication with prison staff in clinical records.

Verbatim wording from the response

“All Healthcare staff attending prisoners have been informed that they must request the welfare checklist document on arrival at the wing, ensuring they have read and understood the entries to inform clinical decision making. This will be evidenced by them signing the sheet to say they have reviewed the information and their entry in the clinical record will state they have reviewed the welfare checklist and communicated with prison staff as part of their clinical assessment. In addition to this, assurance checks will be completed monthly by the Primary Care Manager who will review the welfare check sheets ensuring the attending staff have reviewed and signed the sheets as part of their assessment. This will be cross referenced with the clinical record to ensure that this information was considered when undertaking the assessment.”

Source location

Response from Greater Manchester Mental Health
Page 2 · response
Published 9 May 2024

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

Meet with HMP Garth governors to address welfare checklist concerns.

Verbatim wording from the response

“Following the conclusion of the Inquest, ████████, Head of Healthcare for HMP Garth has met with the Governors of HMP Garth, ████████, to address these concerns.”

Source location

Response from Greater Manchester Mental Health
Page 1 · response
Published 9 May 2024

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

Hold joint prison and healthcare meetings to establish a joined-up approach to welfare checks.

Verbatim wording from the response

“In the meantime, I have received assurance from the Governor of HMP Garth that following the inquest meetings have been held between prison and healthcare colleagues to ensure a joined up approach going forward. Once national guidance is available, a standard operating procedure will be produced so that all prison and healthcare staff understand what they are expected to do when carrying out welfare checks on prisoners being monitored under the influence. GMMH have also committed to developing local training and awareness sessions around the use of the welfare check sheet once national guidance has been published.”

Source location

Response from HMPPS
Page 2 · response
Published 9 May 2024

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

Produce a standard operating procedure defining prison and healthcare staff responsibilities when conducting welfare checks on prisoners monitored under the influence.

Verbatim wording from the response

“In the meantime, I have received assurance from the Governor of HMP Garth that following the inquest meetings have been held between prison and healthcare colleagues to ensure a joined up approach going forward. Once national guidance is available, a standard operating procedure will be produced so that all prison and healthcare staff understand what they are expected to do when carrying out welfare checks on prisoners being monitored under the influence. GMMH have also committed to developing local training and awareness sessions around the use of the welfare check sheet once national guidance has been published.”

Source location

Response from HMPPS
Page 2 · response
Published 9 May 2024

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 and consult on national guidance for managing prisoners under the influence of illicit substances, incorporating the reported welfare-check concerns.

Verbatim wording from the response

“I am pleased to inform you that HMPPS is currently developing national guidance for all staff managing prisoners who are under the influence of illicit substances. The guidance has been developed by the national Substance Misuse Group with contributions from internal and external stakeholders, including from areas such as health, and safety. Its purpose is to provide structured guidance for prisons to support the development of local under the influence guidance that will ensure that there is a consistent and safe response to the management of prisoners. It is important to note that this guidance does not replace healthcare advice and in a medical emergency instructions and advice from healthcare colleagues must be followed as a priority.”

Source location

Response from HMPPS
Page 1 · response
Published 9 May 2024

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

HMPPS is developing national guidance addressing welfare checklist concerns about purpose, completion guidance and joint consideration.

Verbatim wording from the response

“Our prison partners have informed us that nationally the picture has changed. His Majesties Prison and Probation Service (HMPPS) are developing national guidance for the management of people under the influence and that this process is currently going through consultation with”

Source location

Response from Greater Manchester Mental Health
Page 1 · response
Published 9 May 2024

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

GMMH will provide local training and awareness on using the welfare check sheet after national guidance is published.

Verbatim wording from the response

“I am aware that Greater Manchester Mental Health (GMMH) NHS Foundation Trust have responded separately and therefore my response will focus on matters within the remit of HMPPS.”

Source location

Response from HMPPS
Page 1 · response
Published 9 May 2024

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.5

  1. 1

    Co-produce a standard operating procedure with prison staff after national guidance is published.

    Stated by Greater Manchester Mental Health NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 9 May 2024.
  2. 2

    Share the co-produced standard operating procedure widely with prison colleagues.

    Stated by Greater Manchester Mental Health NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 9 May 2024.
  3. 3

    Conduct assurance checks through the rolling support programme to confirm that under-the-influence guidance is developed and embedded at each prison.

    Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 9 May 2024.
  4. 4

    Develop local guidance at each prison for managing prisoners under the influence of illicit substances.

    Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 9 May 2024.
  5. 5

    Roll out the agreed national guidance through regional and local drug strategy leads.

    Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 9 May 2024.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    Regional and local drug strategy leads will develop local guidance once the national guidance is agreed.

    Stated by HM Prison and Probation ServiceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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

Co-produce a standard operating procedure with prison staff after national guidance is published.

Verbatim wording from the response

“A Standard Operating Procedure (SOP) will be co-produced with prison staff following the publication of national guidance from HMPPS for prisoners who present as under the influence. This SOP will be shared widely with colleagues across the prison. We would be happy to provide a copy of this document to your Coronial Office should you wish.”

Source location

Response from Greater Manchester Mental Health
Page 2 · response
Published 9 May 2024

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 co-produced standard operating procedure widely with prison colleagues.

Verbatim wording from the response

“A Standard Operating Procedure (SOP) will be co-produced with prison staff following the publication of national guidance from HMPPS for prisoners who present as under the influence. This SOP will be shared widely with colleagues across the prison. We would be happy to provide a copy of this document to your Coronial Office should you wish.”

Source location

Response from Greater Manchester Mental Health
Page 2 · response
Published 9 May 2024

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 assurance checks through the rolling support programme to confirm that under-the-influence guidance is developed and embedded at each prison.

Verbatim wording from the response

“Once agreed, the guidance document will be rolled out via the regional and local drug strategy leads, and they will be responsible for developing local guidance. The Substance Misuse Group will deliver additional training and support if necessary, and through their rolling programme of support, assurance checks will be conducted to ensure that under the influence guidance has been developed and embedded at each prison.”

Source location

Response from HMPPS
Page 2 · response
Published 9 May 2024

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 local guidance at each prison for managing prisoners under the influence of illicit substances.

Verbatim wording from the response

“Once agreed, the guidance document will be rolled out via the regional and local drug strategy leads, and they will be responsible for developing local guidance. The Substance Misuse Group will deliver additional training and support if necessary, and through their rolling programme of support, assurance checks will be conducted to ensure that under the influence guidance has been developed and embedded at each prison.”

Source location

Response from HMPPS
Page 2 · response
Published 9 May 2024

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

Roll out the agreed national guidance through regional and local drug strategy leads.

Verbatim wording from the response

“Once agreed, the guidance document will be rolled out via the regional and local drug strategy leads, and they will be responsible for developing local guidance. The Substance Misuse Group will deliver additional training and support if necessary, and through their rolling programme of support, assurance checks will be conducted to ensure that under the influence guidance has been developed and embedded at each prison.”

Source location

Response from HMPPS
Page 2 · response
Published 9 May 2024

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

Regional and local drug strategy leads will develop local guidance once the national guidance is agreed.

Verbatim wording from the response

“Once agreed, the guidance document will be rolled out via the regional and local drug strategy leads, and they will be responsible for developing local guidance. The Substance Misuse Group will deliver additional training and support if necessary, and through their rolling programme of support, assurance checks will be conducted to ensure that under the influence guidance has been developed and embedded at each prison.”

Source location

Response from HMPPS
Page 2 · response
Published 9 May 2024

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