PFD report

Liam SMITH · Prevention of Future Deaths report

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Issued 18 Sep 2015•Worcestershire

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
5

Raised in this report

Recipients
2

Named on the report

Responses found
3

Of 2 recipients

Stated actions
7

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 raised5

  1. Limited healthcare staff interaction with prisoners at high risk from drug use
    Part of recurring concern: Inadequate engagement with prisoners at risk from drug use
  2. Failure by healthcare staff to read relevant sections of System 1 notes
  3. Failure to disseminate relevant medical risk information to staff involved in prisoner care
    Part of recurring concern: Unreliable sharing of safety-critical risk information within prisonsPart of recurring concern: Unsafe interoperability between prison custody and healthcare procedures
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.6

  1. Action

    Take the SystmOne summary-page information issue forward through the West Midlands Regional SystmOne User Group.

    Stated by HM Prison and Probation Service and Herefordshire and Worcestershire Health and Care NHS Trust and Hewell PrisonStated in progressThe respondent said that this action was in progress when they made their response on 18 September 2015.
  2. Action

    Reiterate clinical staff obligations to review relevant sections of healthcare records.

    Stated by HM Prison and Probation Service and Herefordshire and Worcestershire Health and Care NHS Trust and Hewell PrisonStated completedThe respondent said that this action was complete when they made their response on 18 September 2015.
  3. Action

    Change high-risk drug-user detoxification practices by providing next-day caseworker contact and introducing a follow-up SystmOne ledger within three working days of programme completion.

    Stated by HM Prison and Probation Service and Herefordshire and Worcestershire Health and Care NHS Trust and Hewell PrisonStated completedThe respondent said that this action was complete when they made their response on 18 September 2015.

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

  1. Position

    ACCT procedures do not require automatic opening whenever risk may be indicated; staff must assess risk, consult appropriately and record their decision.

    Stated by HM Prison and Probation Service and Herefordshire and Worcestershire Health and Care NHS Trust and Hewell PrisonDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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

Limited healthcare staff interaction with prisoners at high risk from drug use

Wider context from the report

“(4) Evidence suggested only limited interaction between members of Healthcare Staff and prisoners who were deemed as "high risk drug users" with a concern that warning signs are missed ”

Is this part of a recurring concern?

Yes — Inadequate engagement with prisoners at risk from drug use.

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 by healthcare staff to read relevant sections of System 1 notes

Wider context from the report

“(3) Healthcare Staff indicated that they do not always read relevant sections of the System 1 notes and that the "summary page" of System 1 does not always "pull through" relevant important information with a result that staff may be unaware of that information. ”

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 disseminate relevant medical risk information to staff involved in prisoner care

Wider context from the report

“(2) Evidence was given that certain medical information which arrived at the prison with Mr Smith was not disseminated to those in reception for those who had later dealings with him which meant that they were unaware of the potential risk of suicide or self harm. It was suggested by some witnesses that documentation "goes astray" and is only found much later. ”

Is this part of a recurring concern?

Yes — Unreliable sharing of safety-critical risk information within prisons; Unsafe interoperability between prison custody and healthcare 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 to follow mandatory ACCT procedures for prisoners at risk of self-harm

Wider context from the report

“(1) Evidence suggested that Mr Smith was at risk of inadvertant self harm and that therefore in accordance with PSI64/2011 ACCT procedures should have been opened in respect of him. Witnesses confirmed their understanding of that mandatory requirement but indicated that they would use their clinical judgement in deciding whether or not to open an ACCT. It is of concern that staff may therefore may therefore not be following mandatory PSI instructions and that prisoners are not receiving appropriate protection by way of the ACCT process. ”

Is this part of a recurring concern?

Yes — Ineffective prison suicide and self-harm prevention systems; Unreliable ACCT suicide and self-harm prevention processes.

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 the System 1 summary page to display relevant important information

Wider context from the report

“(3) Healthcare Staff indicated that they do not always read relevant sections of the System 1 notes and that the "summary page" of System 1 does not always "pull through" relevant important information with a result that staff may be unaware of that information. ”

Is this part of a recurring concern?

Yes — Electronic patient records failing to make relevant clinical information available and actionable.

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

Take the SystmOne summary-page information issue forward through the West Midlands Regional SystmOne User Group.

Verbatim wording from the response

“The concerns you have raised regarding healthcare staff not reading relevant sections of the records have been taken very seriously. All registered clinical staff have a professional obligation to review relevant parts of the notes; this message has been reiterated and addressed with all clinical staff. The second part of the concern relates to information being ‘pulled through’ onto the summary page. This matter is being taken forward with the West Midlands Regional SystmOne User Group so that the learning generated through Mr Smith’s death can be shared much wider than one prison. In the meantime, this issue has been raised with clinical staff in a staff meeting at HMP Hewell and the learning is being disseminated across the three prisons in which the Trust provides healthcare.”

Source location

2015-0382-Response-by-NOMS
Page 2 · response
Published 18 September 2015

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

Reiterate clinical staff obligations to review relevant sections of healthcare records.

Verbatim wording from the response

“The concerns you have raised regarding healthcare staff not reading relevant sections of the records have been taken very seriously. All registered clinical staff have a professional obligation to review relevant parts of the notes; this message has been reiterated and addressed with all clinical staff. The second part of the concern relates to information being ‘pulled through’ onto the summary page. This matter is being taken forward with the West Midlands Regional SystmOne User Group so that the learning generated through Mr Smith’s death can be shared much wider than one prison. In the meantime, this issue has been raised with clinical staff in a staff meeting at HMP Hewell and the learning is being disseminated across the three prisons in which the Trust provides healthcare.”

Source location

2015-0382-Response-by-NOMS
Page 2 · response
Published 18 September 2015

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

Change high-risk drug-user detoxification practices by providing next-day caseworker contact and introducing a follow-up SystmOne ledger within three working days of programme completion.

Verbatim wording from the response

“The Trust has confirmed that they have now changed their practices relating to high risk drug users. The initial contact for those undergoing any type of detoxification is from the caseworker who has contact the day after the person is received into the prison. Additionally, a follow up ledger to SystmOne has been introduced within three working days of the detoxification programme ending. An audit will be undertaken within the first quarter of 2016 to check that the processes are working effectively.”

Source location

2015-0382-Response-by-NOMS
Page 2 · response
Published 18 September 2015

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

Review the ACCT process to inform changes to PSI 64/2011.

Verbatim wording from the response

“A review of the ACCT process is currently ongoing, which will inform changes to the current policy in PSI 64/2011.”

Source location

2015-0382-Response-by-NOMS
Page 2 · response
Published 18 September 2015

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

Audit high-risk drug-user detoxification processes during the first quarter of 2016.

Verbatim wording from the response

“The Trust has confirmed that they have now changed their practices relating to high risk drug users. The initial contact for those undergoing any type of detoxification is from the caseworker who has contact the day after the person is received into the prison. Additionally, a follow up ledger to SystmOne has been introduced within three working days of the detoxification programme ending. An audit will be undertaken within the first quarter of 2016 to check that the processes are working effectively.”

Source location

2015-0382-Response-by-NOMS
Page 2 · response
Published 18 September 2015

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

Review reception procedures and establish recorded communication between reception staff and escort providers.

Verbatim wording from the response

“It is accepted that the reception processes in relation to communicating with escort staff were not as robust as ideally they should have been. Both the prison and healthcare provider have reviewed their procedures in respect to ensure that systems are in place that communication between reception staff and the escort provider is recorded appropriately. In Mr Smith's case it appears that the Person Escort Record (PER) was not used appropriately, in that the medical in confidence information provided by health care professionals in the court was not attached to the PER.”

Source location

2015-0382-Response-by-NOMS
Page 2 · response
Published 18 September 2015

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

ACCT procedures do not require automatic opening whenever risk may be indicated; staff must assess risk, consult appropriately and record their decision.

Verbatim wording from the response

“As you are aware, chapter 5 of Prison Service Instruction (PSI) 64/2011 sets out the policy on the Assessment, Care in Custody and Teamwork (ACCT) process. ACCT is a prisoner-centred, flexible care planning approach which is used in all prisons to manage a prisoner's risk or self-harm or suicide.”

Source location

2015-0382-Response-by-NOMS
Page 1 · response
Published 18 September 2015

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.1

  1. 1

    Raise SystmOne information concerns with Hewell clinical staff and disseminate learning across the Trust's three prisons.

    Stated by HM Prison and Probation Service and Herefordshire and Worcestershire Health and Care NHS Trust and Hewell PrisonStated completedThe respondent said that this action was complete when they made their response on 18 September 2015.

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

Raise SystmOne information concerns with Hewell clinical staff and disseminate learning across the Trust's three prisons.

Verbatim wording from the response

“The concerns you have raised regarding healthcare staff not reading relevant sections of the records have been taken very seriously. All registered clinical staff have a professional obligation to review relevant parts of the notes; this message has been reiterated and addressed with all clinical staff. The second part of the concern relates to information being ‘pulled through’ onto the summary page. This matter is being taken forward with the West Midlands Regional SystmOne User Group so that the learning generated through Mr Smith’s death can be shared much wider than one prison. In the meantime, this issue has been raised with clinical staff in a staff meeting at HMP Hewell and the learning is being disseminated across the three prisons in which the Trust provides healthcare.”

Source location

2015-0382-Response-by-NOMS
Page 2 · response
Published 18 September 2015

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