PFD report

Satheeskumar MAHATHEVAN · Prevention of Future Deaths report

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Issued 19 Sep 2014•Inner North London

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
6

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
10

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 raised6

  1. Failure of multi-agency communication procedures
    Part of recurring concern: Unreliable multi-agency communication procedures
  2. Failure of multi-agency communication procedures
    Part of recurring concern: Unreliable multi-agency communication procedures
  3. Failures in information sharing
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

    Obtain prisoners’ consent through an information-sharing form to support necessary information exchange and continuity of care between establishments.

    Stated by Pentonville Prison and Thameside PrisonStated completedThe respondent said that this action was complete when they made their response on 19 September 2014.
  2. Action

    Review electronic medical records for transferred prisoners and provide verbal handovers between sending and receiving prisons when wellbeing concerns arise.

    Stated by Pentonville Prison and Thameside PrisonStated completedThe respondent said that this action was complete when they made their response on 19 September 2014.
  3. Action

    Implement local information-sharing and multi-agency communication policies, including staff reminders on gathering, assessing and sharing risk information.

    Stated by Pentonville Prison and Thameside PrisonStated completedThe respondent said that this action was complete when they made their response on 19 September 2014.

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 multi-agency communication procedures

Wider context from the report

““Failures in relation to information sharing, multi agency communication procedures and inadequate training for staff at the prison services have contributed to this accident.” ”

Is this part of a recurring concern?

Yes — Unreliable multi-agency communication procedures.

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 multi-agency communication procedures

Wider context from the report

““Failures in relation to information sharing, multi agency communication procedures and inadequate training for staff at the prison services have contributed to this accident.” ”

Is this part of a recurring concern?

Yes — Unreliable multi-agency communication procedures.

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

Failures in information sharing

Wider context from the report

““Failures in relation to information sharing, multi agency communication procedures and inadequate training for staff at the prison services have contributed to this accident.” ”

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

Inadequate training for prison service staff

Wider context from the report

““Failures in relation to information sharing, multi agency communication procedures and inadequate training for staff at the prison services have contributed to this accident.” ”

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

Inadequate staff training in prison services

Wider context from the report

““Failures in relation to information sharing, multi agency communication procedures and inadequate training for staff at the prison services have contributed to this accident.” ”

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 information sharing

Wider context from the report

““Failures in relation to information sharing, multi agency communication procedures and inadequate training for staff at the prison services have contributed to this accident.” ”

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

Obtain prisoners’ consent through an information-sharing form to support necessary information exchange and continuity of care between establishments.

Verbatim wording from the response

“On arrival at each prison, prisoners are requested to sign an "information sharing" form, which provides consent for necessary information to be shared as required, so ensuring continuity of care between establishments.”

Source location

2014-0412-Response-by-NOMS
Page 2 · response
Published 19 September 2014

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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 electronic medical records for transferred prisoners and provide verbal handovers between sending and receiving prisons when wellbeing concerns arise.

Verbatim wording from the response

“Both prisons currently use electronic medical records (SystmOne) and on receipt of a prisoner on transfer the healthcare staff in reception read all relevant information on this system to ensure that they are fully aware of their health needs. Where there are concerns with a prisoner’s well-being, the sending prison contacts the receiving prison to ensure that there is a verbal handover in addition to immediate access to the clinical records.”

Source location

2014-0412-Response-by-NOMS
Page 2 · response
Published 19 September 2014

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 local information-sharing and multi-agency communication policies, including staff reminders on gathering, assessing and sharing risk information.

Verbatim wording from the response

“Local policies are now in place at HMP Pentonville and HMP Thameside to ensure that information is shared appropriately and that there is effective communication between prison staff and the healthcare provider. At both prisons, staff involved in the reception and first night processes have been reminded of the need to gather all relevant information, including information received from court, and of the factors that they should consider when assessing risk and sharing information between agencies.”

Source location

2014-0412-Response-by-NOMS
Page 1 · response
Published 19 September 2014

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

Train Pentonville healthcare staff to use PNOMIS for recording prisoner information and obtaining community records.

Verbatim wording from the response

“All healthcare staff at HMP Pentonville are also being trained in the use of PNOMIS to record prisoner information and made aware of how to obtain community records.”

Source location

2014-0412-Response-by-NOMS
Page 2 · response
Published 19 September 2014

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

Provide Pentonville reception healthcare staff with court documentation and use staged checks and verbal handovers to identify and communicate relevant health-risk information.

Verbatim wording from the response

“At HMP Pentonville healthcare staff in reception now have access to all the relevant documents that arrive with the prisoner from court. This will include the prisoner escort record, core record, self harm warning form, custody record from police, and/or F2050 which contains the prisoner’s warrant. The procedure is that on the arrival of a new prisoner the supervising officer on the reception desk checks the accompanying documentation. If any information regarding the prisoner’s physical or mental health is identified this will be handed to the healthcare staff. The prisoner’s file is then passed to staff on the induction wing who conduct a further check of the documentation, providing a second opportunity for relevant information to be found should it have been missed initially.”

Source location

2014-0412-Response-by-NOMS
Page 1 · response
Published 19 September 2014

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

Enable prison and healthcare staff at Thameside to work together at reception and use a dedicated form to communicate relevant prisoner information.

Verbatim wording from the response

“At HMP Thameside prison and healthcare staff work together at the same counter. A new form has been designed specifically to ensure that all relevant information, including that received from the court, is communicated between the two groups of staff.”

Source location

2014-0412-Response-by-NOMS
Page 2 · response
Published 19 September 2014

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

Train new healthcare staff to use SystmOne correctly and require demonstrated confidence before granting unsupervised access.

Verbatim wording from the response

“All new healthcare staff are shown how to use the SystmOne electronic record system correctly, and must be confident in using the system before being allowed access without supervision.”

Source location

2014-0412-Response-by-NOMS
Page 2 · response
Published 19 September 2014

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

Routinely request community GP and other relevant health records where prisoners have health concerns, documenting all contact attempts electronically.

Verbatim wording from the response

“Community GP records are now routinely requested in all cases in which there are health concerns. All attempts to contact GPs and other relevant agencies are clearly documented on the SystmOne electronic record.”

Source location

2014-0412-Response-by-NOMS
Page 2 · response
Published 19 September 2014

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.2

  1. 1

    Issue revised instructions requiring communications staff to call an ambulance immediately when the relevant emergency code is used.

    Stated by Pentonville Prison and Thameside PrisonStated plannedThe respondent said that this action was planned when they made their response on 19 September 2014.
  2. 2

    Issue revised guidance to Pentonville staff on using appropriate doctors during medical emergencies.

    Stated by Pentonville Prison and Thameside PrisonStated plannedThe respondent said that this action was planned when they made their response on 19 September 2014.

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

Issue revised instructions requiring communications staff to call an ambulance immediately when the relevant emergency code is used.

Verbatim wording from the response

“In December 2014 HMP Pentonville will be issuing revised guidance to all staff to ensure that appropriate doctors are used in the event of a medical emergency. Communications from staff will also receive revised instructions to ensure that an ambulance is called immediately on the relevant code being used.”

Source location

2014-0412-Response-by-NOMS
Page 2 · response
Published 19 September 2014

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

Issue revised guidance to Pentonville staff on using appropriate doctors during medical emergencies.

Verbatim wording from the response

“In December 2014 HMP Pentonville will be issuing revised guidance to all staff to ensure that appropriate doctors are used in the event of a medical emergency. Communications from staff will also receive revised instructions to ensure that an ambulance is called immediately on the relevant code being used.”

Source location

2014-0412-Response-by-NOMS
Page 2 · response
Published 19 September 2014

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