PFD report

Adam Amos Williams · Prevention of Future Deaths report

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Issued 14 Jul 2014•Staffordshire South

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
3

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
3

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 raised3

  1. Insufficient CCTV coverage in prison common areas
    Part of recurring concern: Inadequate CCTV coverage and monitoring in custodial settings
  2. Inadequate communication between healthcare staff during emergencies
    Part of recurring concern: Ineffective communication during medical emergencies
  3. Failure of dynamic assessments to account for the need for prisoner restraint
    Part of recurring concern: Unreliable safety risk assessments for prisoners
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.3

  1. Action

    Ensure two healthcare staff attend every health emergency radio call, with lone nurses requesting colleague attendance.

    Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 14 July 2014.
  2. Action

    Provide escort and duty managers with emergency-escort advice and guidance, and review restraint decisions at operational meetings.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 14 July 2014.
  3. Action

    Apply an individual, audit-compliant escort risk assessment to determine restraint use, including reassessment following medical advice.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 14 July 2014.

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

  1. Position

    CCTV cannot be installed throughout all prison areas because the required infrastructure and staff monitoring cannot be resourced.

    Stated by HM Prison and Probation ServiceUnable 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

Insufficient CCTV coverage in prison common areas

Wider context from the report

“(3) Although I accept that resource factors must be taken into account in this, I wonder if it may be beneficial for there to be more CCTV in common areas of the prison such as the gym or CV rooms. ”

Is this part of a recurring concern?

Yes — Inadequate CCTV coverage and monitoring in custodial settings.

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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 communication between healthcare staff during emergencies

Wider context from the report

“(1) Picking up on recommendation 2 from the Prisons and Probation Ombudsman’s report I wonder if there is a training need for nursing staff at the prison regarding communication between healthcare staff in the event of an emergency. Can it be improved be it face to face, over the radio or otherwise? ”

Is this part of a recurring concern?

Yes — Ineffective communication during medical emergencies.

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 dynamic assessments to account for the need for prisoner restraint

Wider context from the report

“(2) Picking up on recommendation 3 in the Prisons and Probation Ombudsman’s report I wonder if the “dynamic assessment” referred to does specifically take into account the need for a prisoner to be restrained at all. ”

Is this part of a recurring concern?

Yes — Unreliable safety risk assessments for prisoners.

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

Ensure two healthcare staff attend every health emergency radio call, with lone nurses requesting colleague attendance.

Verbatim wording from the response

“The sharing of medical information over the radio has been considered by the prison and healthcare provider who are conscious that a secure bandwidth would need to be available for this process to be able to share confidential information over the airways. However, at present two members of healthcare staff are expected to attend emergency calls throughout the day, and at weekends when staffing is reduced a single staff member attends emergency calls. In the future, Healthcare staff will ensure two members of staff attend all health emergency calls over the radio. Where nurses are completing tasks alone and are called to attend a Code Red or Code Blue emergency, they should request another colleague to attend by making the request over the radio.”

Source location

2014-0324-Response-by-NOMS
Page 1 · response
Published 14 July 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

Provide escort and duty managers with emergency-escort advice and guidance, and review restraint decisions at operational meetings.

Verbatim wording from the response

“that a prisoner is in a life threatening condition then cuffs will not routinely be applied. Where medical professionals or our staff are in doubt about the physical condition of the prisoner, a risk assessment will be completed to ascertain whether cuffs will be applied. This can be reviewed at any point following advice from medical professionals. Since the escort and duty managers have received advice and guidance on emergency escorts, and this issue is regularly reviewed at morning operational meetings by the Senior Management Team (SMT) to discuss whether the level of restraint applied at recent hospital visits was appropriate.”

Source location

2014-0324-Response-by-NOMS
Page 2 · response
Published 14 July 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

Apply an individual, audit-compliant escort risk assessment to determine restraint use, including reassessment following medical advice.

Verbatim wording from the response

“At HMP Featherstone a standard risk assessment proforma is in place for all external escorts, which is audit compliant. This is completed on an individual basis for each prisoner which considers various risk factors, such as criminal history, behaviour in prison, risk to the public, risk to the victim and escape potential. Where it is confirmed”

Source location

2014-0324-Response-by-NOMS
Page 1 · response
Published 14 July 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

CCTV cannot be installed throughout all prison areas because the required infrastructure and staff monitoring cannot be resourced.

Verbatim wording from the response

“The requirement for CCTV in common areas of the prison is risk assessed, and dependant on the need in that area. It is not possible to install CCTV in every area of the prison due to the resource implication; however the location of unsupervised CV rooms enables staff to promptly attend when required. The effectiveness of CCTV is dependant on staff being available to simultaneously watch the CCTV camera, which cannot be resourced. An analysis of reported incidents for the year to date shows that incidents in CV rooms are extremely rare and therefore there are no plans at present to extend the use of CCTV cameras at Featherstone.”

Source location

2014-0324-Response-by-NOMS
Page 2 · response
Published 14 July 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

Existing individual escort risk assessments, guidance and operational reviews are considered sufficient to determine whether prisoners require restraints.

Verbatim wording from the response

“At HMP Featherstone a standard risk assessment proforma is in place for all external escorts, which is audit compliant. This is completed on an individual basis for each prisoner which considers various risk factors, such as criminal history, behaviour in prison, risk to the public, risk to the victim and escape potential. Where it is confirmed”

Source location

2014-0324-Response-by-NOMS
Page 1 · response
Published 14 July 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

No further CCTV extension is planned because incidents in cardiovascular rooms are rare and staff can promptly attend those areas when needed.

Verbatim wording from the response

“The requirement for CCTV in common areas of the prison is risk assessed, and dependant on the need in that area. It is not possible to install CCTV in every area of the prison due to the resource implication; however the location of unsupervised CV rooms enables staff to promptly attend when required. The effectiveness of CCTV is dependant on staff being available to simultaneously watch the CCTV camera, which cannot be resourced. An analysis of reported incidents for the year to date shows that incidents in CV rooms are extremely rare and therefore there are no plans at present to extend the use of CCTV cameras at Featherstone.”

Source location

2014-0324-Response-by-NOMS
Page 2 · response
Published 14 July 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