PFD report

Carol Taylor · Prevention of Future Deaths report

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Issued 12 Jun 2025•Essex

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
1

Raised in this report

Recipients
1

Named on the report

Responses found
3

Of 1 recipient

Stated actions
19

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

Open published report

Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised1

  1. Failure to prevent staff non-compliant with mandatory training from working on inpatient wards
    Part of recurring concern: Failure to ensure mandatory safety training is completed before safety-critical work
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.1

  1. Action

    Manage mandatory-training compliance using ward training trackers, monthly reviews, expiry alerts, booking support and escalation of non-compliant temporary staff.

    Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 June 2025.

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

  1. Position

    A complete bar on staff lacking mandatory training is not implemented because it risks insufficient staffing levels on wards.

    Stated by Essex Partnership University NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant 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

Failure to prevent staff non-compliant with mandatory training from working on inpatient wards

Wider context from the report

“(1) There is no system that prevents staff that are non- compliant with mandatory training, including basic life support training, from being able to work on EPUT in- patient wards. (2) This is a particular concern generally, but especially in hospitals such as St Margaret’s where at least some of the wards specialise in treating elderly patients who are likely to be at greater risk of medical collapse than the general population. ”

Is this part of a recurring concern?

Yes — Failure to ensure mandatory safety training is completed before safety-critical work.

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

Manage mandatory-training compliance using ward training trackers, monthly reviews, expiry alerts, booking support and escalation of non-compliant temporary staff.

Verbatim wording from the response

“Response: Ward managers are able to access and review the skills of staff on the ward, which includes bank worker training compliance, via a training tracker. If there is a staff shortage then requests may be made for bank and agency staff, identifying the skill set required to ensure those booked onto shift hold the necessary skills / training to deliver the required care competently.”

Source location

Response from Essex Partnership University NHS Trust
Page 1 · response
Published 19 June 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

A complete bar on staff lacking mandatory training is not implemented because it risks insufficient staffing levels on wards.

Verbatim wording from the response

“A ‘bar’ on temporary staff / substantive working on the ward unless they are compliant with all mandatory training, including basic life support training brings the significant risk in relation to having the necessary number of staff on shift however compliance with mandatory training is vital. To address this Ward Managers actively manage compliance with mandatory training.”

Source location

Response from Essex Partnership University NHS Trust
Page 1 · response
Published 19 June 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

Operational concerns are assigned to HMPPS, whose Interim Director General of Operations has responsibility for responding to them.

Verbatim wording from the response

“The concerns you have raised within your report are operational issues and it is therefore appropriate that ████████ who is the Interim Director General of Operations, HM Prison and Probation Service (HMPPS), has responded to them. I have seen the response from ████████ and I endorse the content of it, which sets out the action being taken by HMPPS to address your concerns.”

Source location

Response from Ministry of Justice
Page 1 · response
Published 19 June 2025

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.18

  1. 1

    Introduce a booking tool for ACCT reviews and flag missed reviews to the Orderly Officer for prompt rescheduling.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 19 June 2025.
  2. 2

    Operate a priority key work scheme to ensure the most vulnerable men are seen regularly.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 19 June 2025.
  3. 3

    Publish guidance for prison and probation staff on managing self-neglect in prisons and approved premises.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 19 June 2025.
  4. 4

    Implement three-stage ACCT quality assurance, including weekly checks of open documents and twice-monthly regional Safety Team assurance visits.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 19 June 2025.
  5. 5

    Introduce a shift pattern assigning officers to increase key work sessions and improve continuity with the same key worker where possible.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 19 June 2025.
  6. 6

    Review the next-of-kin recording process and involve the Offender Management Unit to manage it effectively.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 19 June 2025.
  7. 7

    Issue mandatory ambulance-call instructions for emergency codes and regularly review compliance.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 19 June 2025.
  8. 8

    Provide 84 Physical Health Link Practitioners across inpatient wards and involve them in bi-monthly Resus Link Practitioner meetings for shared learning.

    Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 June 2025.
  9. 9

    Deliver and record a Trust online Learning Matters event presenting emergency-care resources and previous lessons for staff’s future access.

    Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 June 2025.
  10. 10

    Induct ward and clinical-area staff in summoning help during medical emergencies through basic and immediate life-support training and supporting documents.

    Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 June 2025.
  11. 11

    Appoint a Resus Link Practitioner on each ward to share learning and safety alerts and facilitate regular medical-emergency simulations.

    Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 June 2025.
  12. 12

    Use structured SBAR handovers and a dedicated emergency-call document to support escalation and ambulance-service communication.

    Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 June 2025.
  13. 13

    Explore implementing the Physical Health Competency Framework and bite-sized training packages across the Trust.

    Stated by Essex Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 June 2025.
  14. 14

    Provide NEWS2 training to staff at the relevant sites and signpost staff to online deterioration-recognition and management training.

    Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 June 2025.
  15. 15

    Pilot the Physical Health Secondary Care Planning Cycle on selected inpatient wards.

    Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 June 2025.
  16. 16

    Monitor the safety provisions described to assess their contribution to patient safety.

    Stated by Essex Partnership University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 19 June 2025.
  17. 17

    Implement Trust-wide physical-health assessment and non-contact-observation aide-memoires to support robust patient assessments.

    Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 June 2025.
  18. 18

    Operate a Physical Health Task and Finish Group to review physical-health provision on inpatient wards.

    Stated by Essex Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 June 2025.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.2

  1. 1

    Staffing issues prevented Guys Marsh from operating key work in accordance with national guidance.

    Stated by HM Prison and Probation ServiceUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
  2. 2

    No problems had previously arisen from the similarity in colour between cell doors and bedsheets.

    Stated by HM Prison and Probation ServiceDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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

Introduce a booking tool for ACCT reviews and flag missed reviews to the Orderly Officer for prompt rescheduling.

Verbatim wording from the response

“Your report draws attention to the absence of a system for flagging missed ACCT reviews at Guys Marsh, and to the fact that relevant individuals were not being invited to reviews. A new booking tool was introduced in August 2024 to schedule reviews, and this also supports consistent attendance from relevant individuals. The safety team now highlights any reviews that have been missed to the Orderly Officer so that they can be rescheduled promptly.”

Source location

Response from HM Prison & Probation Services
Page 2 · response
Published 19 June 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

Operate a priority key work scheme to ensure the most vulnerable men are seen regularly.

Verbatim wording from the response

“Your report notes that key work at Guys Marsh was not operating in accordance with key work national guidance. This has not been possible because of staffing issues, but the prison has been operating a priority key work scheme, designed to ensure that the most vulnerable men are seen regularly. A new shift pattern was introduced in September 2024 detailing officers to carry out key work to increase the delivery of key work sessions beyond the priority group as well as providing consistency with sessions being delivered by the same key worker where possible.”

Source location

Response from HM Prison & Probation Services
Page 2 · response
Published 19 June 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

Publish guidance for prison and probation staff on managing self-neglect in prisons and approved premises.

Verbatim wording from the response

“Your report identifies a lack of guidance on the management of self-neglect in the prison setting. Informed by the learning from the investigations into Mr Williams’ death, guidance for prison and probation staff on ‘Managing Self-Neglect in Prisons and Approved Premises’ was published on the HMPPS intranet in July 2024. This is designed to raise awareness of the issue amongst staff and to equip them to work in partnership with healthcare staff to safeguard people who self-neglect in a prison or an approved premise.”

Source location

Response from HM Prison & Probation Services
Page 1 · response
Published 19 June 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

Implement three-stage ACCT quality assurance, including weekly checks of open documents and twice-monthly regional Safety Team assurance visits.

Verbatim wording from the response

“Your report describes a lack of quality assurance of the operation of the Assessment, Care in Custody and Teamwork (ACCT) process. The Prison Safety Policy Framework that was implemented on 1 January 2025 mandates the use of a quality assurance tool which involves a three-stage check of ACCT documents, including a weekly check of all open ACCT document. At Guys Marsh this local assurance process is supplemented by the regional Safety Team which attends the prison twice monthly to undertake ACCT assurance and provide feedback to the establishment.”

Source location

Response from HM Prison & Probation Services
Page 2 · response
Published 19 June 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

Introduce a shift pattern assigning officers to increase key work sessions and improve continuity with the same key worker where possible.

Verbatim wording from the response

“Your report notes that key work at Guys Marsh was not operating in accordance with key work national guidance. This has not been possible because of staffing issues, but the prison has been operating a priority key work scheme, designed to ensure that the most vulnerable men are seen regularly. A new shift pattern was introduced in September 2024 detailing officers to carry out key work to increase the delivery of key work sessions beyond the priority group as well as providing consistency with sessions being delivered by the same key worker where possible.”

Source location

Response from HM Prison & Probation Services
Page 2 · response
Published 19 June 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

Review the next-of-kin recording process and involve the Offender Management Unit to manage it effectively.

Verbatim wording from the response

“Your report notes problems with the process for recording information about a prisoner’s next of kin at Guys Marsh. This has been reviewed, and the Offender Management Unit is now involved to ensure that the process is managed effectively.”

Source location

Response from HM Prison & Probation Services
Page 2 · response
Published 19 June 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

Issue mandatory ambulance-call instructions for emergency codes and regularly review compliance.

Verbatim wording from the response

“Your report draws attention to local procedures at Guys Marsh that did not comply with national policy on when to call an ambulance. The Governor has issued a Notice to Staff that explains that it is mandatory to call an ambulance when an emergency code is called, and compliance with this expectation is regularly reviewed.”

Source location

Response from HM Prison & Probation Services
Page 2 · response
Published 19 June 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

Provide 84 Physical Health Link Practitioners across inpatient wards and involve them in bi-monthly Resus Link Practitioner meetings for shared learning.

Verbatim wording from the response

“In addition, there is a Physical Health Task and Finish Group which has been formed to review the existing physical health provision on the inpatient Wards. The Physical Health Competency Framework and Bite Sized Training support packages are amongst a number of resources which are currently being explored for implementation across the Trust. There are 84 Physical Health Link Practitioners in place across the inpatient Wards and the volunteers join the bi-monthly Resus Link Practitioner meetings where learning is shared. A ‘Physical Health Secondary Care planning Cycle’ has been piloted on a number of in-patient wards, with a view to implementing this Trust wide.”

Source location

Response from Essex Partnership University NHS Trust
Page 2 · response
Published 19 June 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

Deliver and record a Trust online Learning Matters event presenting emergency-care resources and previous lessons for staff’s future access.

Verbatim wording from the response

“Each Ward has a nominated Resus Link Practitioner to aid in sharing lessons identified and safety alerts and helping to facilitate regular medical emergency simulations within the clinical areas. These important resources and previous lessons identified were presented to EPUT staff via an online ‘Learning Matters’ event which was delivered on 25th June 2025 and the event was recorded for future access.”

Source location

Response from Essex Partnership University NHS Trust
Page 2 · response
Published 19 June 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

Induct ward and clinical-area staff in summoning help during medical emergencies through basic and immediate life-support training and supporting documents.

Verbatim wording from the response

“Response: Following on from our reply under concern 1 above, all staff working on EPUT wards and clinical areas, are inducted on the process for summoning help in a medical emergency. This is covered in the Basic Life Support (BLS) and Immediate Life Support (ILS) training and is also highlighted on the attached two documents.”

Source location

Response from Essex Partnership University NHS Trust
Page 2 · response
Published 19 June 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

Appoint a Resus Link Practitioner on each ward to share learning and safety alerts and facilitate regular medical-emergency simulations.

Verbatim wording from the response

“Each Ward has a nominated Resus Link Practitioner to aid in sharing lessons identified and safety alerts and helping to facilitate regular medical emergency simulations within the clinical areas. These important resources and previous lessons identified were presented to EPUT staff via an online ‘Learning Matters’ event which was delivered on 25th June 2025 and the event was recorded for future access.”

Source location

Response from Essex Partnership University NHS Trust
Page 2 · response
Published 19 June 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

Use structured SBAR handovers and a dedicated emergency-call document to support escalation and ambulance-service communication.

Verbatim wording from the response

“The Royal College of Physicians NEWS2 training has been undertaken by staff working at these sites and staff are signposted to the additional ‘364 Recognising & Managing Deterioration’ training which is available for all staff to access via the online learning portal. The Assessing a Critically Unwell Patient and ‘Non-Contact Physical Observations’ aide memoires have been implemented Trust wide, in order to support staff members to carry out a robust ‘Head to toe’ physical health assessment of a patient. The situation, background, assessment and recommendation (SBAR) tool is utilised to provide a structured handover upon escalation, whilst the ‘Calling (9)999 in a Medical Emergency’ document assists with communication when contacting the Ambulance Service.”

Source location

Response from Essex Partnership University NHS Trust
Page 2 · response
Published 19 June 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

Explore implementing the Physical Health Competency Framework and bite-sized training packages across the Trust.

Verbatim wording from the response

“In addition, there is a Physical Health Task and Finish Group which has been formed to review the existing physical health provision on the inpatient Wards. The Physical Health Competency Framework and Bite Sized Training support packages are amongst a number of resources which are currently being explored for implementation across the Trust. There are 84 Physical Health Link Practitioners in place across the inpatient Wards and the volunteers join the bi-monthly Resus Link Practitioner meetings where learning is shared. A ‘Physical Health Secondary Care planning Cycle’ has been piloted on a number of in-patient wards, with a view to implementing this Trust wide.”

Source location

Response from Essex Partnership University NHS Trust
Page 2 · response
Published 19 June 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

Provide NEWS2 training to staff at the relevant sites and signpost staff to online deterioration-recognition and management training.

Verbatim wording from the response

“The Royal College of Physicians NEWS2 training has been undertaken by staff working at these sites and staff are signposted to the additional ‘364 Recognising & Managing Deterioration’ training which is available for all staff to access via the online learning portal. The Assessing a Critically Unwell Patient and ‘Non-Contact Physical Observations’ aide memoires have been implemented Trust wide, in order to support staff members to carry out a robust ‘Head to toe’ physical health assessment of a patient. The situation, background, assessment and recommendation (SBAR) tool is utilised to provide a structured handover upon escalation, whilst the ‘Calling (9)999 in a Medical Emergency’ document assists with communication when contacting the Ambulance Service.”

Source location

Response from Essex Partnership University NHS Trust
Page 2 · response
Published 19 June 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

Pilot the Physical Health Secondary Care Planning Cycle on selected inpatient wards.

Verbatim wording from the response

“In addition, there is a Physical Health Task and Finish Group which has been formed to review the existing physical health provision on the inpatient Wards. The Physical Health Competency Framework and Bite Sized Training support packages are amongst a number of resources which are currently being explored for implementation across the Trust. There are 84 Physical Health Link Practitioners in place across the inpatient Wards and the volunteers join the bi-monthly Resus Link Practitioner meetings where learning is shared. A ‘Physical Health Secondary Care planning Cycle’ has been piloted on a number of in-patient wards, with a view to implementing this Trust wide.”

Source location

Response from Essex Partnership University NHS Trust
Page 2 · response
Published 19 June 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

Monitor the safety provisions described to assess their contribution to patient safety.

Verbatim wording from the response

“I hope that I have provided some reassurances around the steps that we have taken to address the issues of concern contained within your report. We know there is an acute need to embed and effect change, hence we will monitor the above provisions to ensure these are contributing to our overall aim of keeping patients safe.”

Source location

Response from Essex Partnership University NHS Trust
Page 2 · response
Published 19 June 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

Implement Trust-wide physical-health assessment and non-contact-observation aide-memoires to support robust patient assessments.

Verbatim wording from the response

“The Royal College of Physicians NEWS2 training has been undertaken by staff working at these sites and staff are signposted to the additional ‘364 Recognising & Managing Deterioration’ training which is available for all staff to access via the online learning portal. The Assessing a Critically Unwell Patient and ‘Non-Contact Physical Observations’ aide memoires have been implemented Trust wide, in order to support staff members to carry out a robust ‘Head to toe’ physical health assessment of a patient. The situation, background, assessment and recommendation (SBAR) tool is utilised to provide a structured handover upon escalation, whilst the ‘Calling (9)999 in a Medical Emergency’ document assists with communication when contacting the Ambulance Service.”

Source location

Response from Essex Partnership University NHS Trust
Page 2 · response
Published 19 June 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

Operate a Physical Health Task and Finish Group to review physical-health provision on inpatient wards.

Verbatim wording from the response

“In addition, there is a Physical Health Task and Finish Group which has been formed to review the existing physical health provision on the inpatient Wards. The Physical Health Competency Framework and Bite Sized Training support packages are amongst a number of resources which are currently being explored for implementation across the Trust. There are 84 Physical Health Link Practitioners in place across the inpatient Wards and the volunteers join the bi-monthly Resus Link Practitioner meetings where learning is shared. A ‘Physical Health Secondary Care planning Cycle’ has been piloted on a number of in-patient wards, with a view to implementing this Trust wide.”

Source location

Response from Essex Partnership University NHS Trust
Page 2 · response
Published 19 June 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

Staffing issues prevented Guys Marsh from operating key work in accordance with national guidance.

Verbatim wording from the response

“Your report notes that key work at Guys Marsh was not operating in accordance with key work national guidance. This has not been possible because of staffing issues, but the prison has been operating a priority key work scheme, designed to ensure that the most vulnerable men are seen regularly. A new shift pattern was introduced in September 2024 detailing officers to carry out key work to increase the delivery of key work sessions beyond the priority group as well as providing consistency with sessions being delivered by the same key worker where possible.”

Source location

Response from HM Prison & Probation Services
Page 2 · response
Published 19 June 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

No problems had previously arisen from the similarity in colour between cell doors and bedsheets.

Verbatim wording from the response

“I have noted your concern regarding the similarity in colour of cell doors and bedsheets, but I am not aware of any problems having arisen previous to this. I have passed your observations on to the national Safety Team to consider as part of their ongoing work on ensuring a safe physical environment for prisoners.”

Source location

Response from HM Prison & Probation Services
Page 2 · response
Published 19 June 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