Connor Steven Paul SMITH · Prevention of Future Deaths report

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Issued 17 Dec 2014•Liverpool

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.

View original report
Concerns
1

Raised in this report

Recipients
4

Named on the report

Responses found
2

Of 4 recipients

Stated actions
2

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 of investigations to verify the accuracy of relevant attendance records

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. Prisons and Probation Ombudsman for England and Wales

    Make four recommendations to the prison addressing depression management, the basic-level incentives scheme, healthcare input into segregation decisions, and bullying investigations.

  2. HM Prison and Probation Service

    Issue senior managers guidance requiring meeting attendance records to be completed accurately and without pre-entered names.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Prisons and Probation Ombudsman for England and Wales

    Services investigated by the PPO are responsible for safeguarding people in custody.

    Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
  2. Prisons and Probation Ombudsman for England and Wales

    The PPO does not believe it can take further specific action beyond its recommendations to the prison.

    Unable to actThe respondent said that a constraint prevented them from taking the relevant action.
  3. Prisons and Probation Ombudsman for England and Wales

    The PPO’s investigation conduct falls outside the usual scope of a Regulation 28 report because of its investigative role.

    Outside remitThe respondent said that this matter was outside its role or authority.

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 investigations to verify the accuracy of relevant attendance records

Wider context from the report

“On the 28th January 2013 the PPO investigator interviewed a PCO with regard to a review hearing under rule 49 - colloquially known as a rule 45 board. The officer was asked about the record of the meeting in which his name had appeared as an attendee. Given the frequency of such meetings the officer could not remember the meeting on the 1st January 2013 but was interviewed about it creating a 15 page transcript. On examination of other witnesses, other documentary evidence and a video of the meeting made it clear that the PCO was not present at the review hearing – his name had been entered on the Segregation Rule 45/Rule 49 Authority for continued segregation before the meeting but he had not been there. This is an area of concern highlighting the quality of the investigation by the PPO where by such an error could in another case prevent lessons from being learnt. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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

Make four recommendations to the prison addressing depression management, the basic-level incentives scheme, healthcare input into segregation decisions, and bullying investigations.

Verbatim wording from the response

“In the sad circumstances of Mr Smith’s death, the Ombudsman made four recommendations to the prison about assessment and management of depression, the operation of the Incentives and Earned Privileges scheme for people on basic, healthcare input into decisions about segregation and investigations into allegations about bullying, which we hope might help prevent future similar deaths. I do not believe there is further specific action that the PPO can take.”

Source location

2014-0540-Response-by-Prisons-Probation-Ombudsman
Page 2 · response
Published 17 December 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

Issue senior managers guidance requiring meeting attendance records to be completed accurately and without pre-entered names.

Verbatim wording from the response

“I understand that your concern relates to the quality of the investigation by the Prisons and Probation Ombudsman. However in raising that concern you have drawn attention to the fact that a member of staff was recorded as having attended a meeting at which he was not present, and I would like to provide reassurance that this issue has been addressed by the Director of HMP Altcourse. A notice has been issued to all senior managers who chair Segregation Review Boards advising them that the documentation for completion at the meeting must not have names entered in advance and that it is their responsibility to check that attendance at the meeting is correctly recorded.”

Source location

2014-0540-Response-by-NOMS
Page 1 · response
Published 17 December 2014

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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

Services investigated by the PPO are responsible for safeguarding people in custody.

Verbatim wording from the response

“As you know, this office is fully committed to helping avoid any future deaths in custody, but I am not clear how we can take any action in relation to the matter you identify which might help avoid any future fatality, which is the avowed purpose of regulation 28 reports. Ultimately, the services we investigate are responsible for safeguarding those in custody. We can only realistically contribute to preventing a recurrence of the circumstances of Mr Smith’s death through the recommendations made in our investigation reports. For that reason, the memorandum of understanding between the PPO and the Coroners’ Society recognises that because of our role it ‘would be unusual for the conduct of the investigation by the PPO to come within [a Regulation 28] report’.”

Source location

2014-0540-Response-by-Prisons-Probation-Ombudsman
Page 1 · response
Published 17 December 2014

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 PPO does not believe it can take further specific action beyond its recommendations to the prison.

Verbatim wording from the response

“In the sad circumstances of Mr Smith’s death, the Ombudsman made four recommendations to the prison about assessment and management of depression, the operation of the Incentives and Earned Privileges scheme for people on basic, healthcare input into decisions about segregation and investigations into allegations about bullying, which we hope might help prevent future similar deaths. I do not believe there is further specific action that the PPO can take.”

Source location

2014-0540-Response-by-Prisons-Probation-Ombudsman
Page 2 · response
Published 17 December 2014

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 PPO’s investigation conduct falls outside the usual scope of a Regulation 28 report because of its investigative role.

Verbatim wording from the response

“As you know, this office is fully committed to helping avoid any future deaths in custody, but I am not clear how we can take any action in relation to the matter you identify which might help avoid any future fatality, which is the avowed purpose of regulation 28 reports. Ultimately, the services we investigate are responsible for safeguarding those in custody. We can only realistically contribute to preventing a recurrence of the circumstances of Mr Smith’s death through the recommendations made in our investigation reports. For that reason, the memorandum of understanding between the PPO and the Coroners’ Society recognises that because of our role it ‘would be unusual for the conduct of the investigation by the PPO to come within [a Regulation 28] report’.”

Source location

2014-0540-Response-by-Prisons-Probation-Ombudsman
Page 1 · response
Published 17 December 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