PFD report

Kevin Dermott · Prevention of Future Deaths report

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Issued 13 Jun 2016•Cheshire

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
8

Raised in this report

Recipients
2

Named on the report

Responses found
3

Of 2 recipients

Stated actions
15

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 raised8

  1. Failure to provide specialist hospital treatment for serious mental illness
    Part of recurring concern: Unreliable access to specialist mental health treatment for serious mental illness
  2. Inadequacies in mental health care planning and communication
    Part of recurring concern: Failure to integrate mental health services across care settingsPart of recurring concern: Failure to provide continuity of patient care
  3. Inadequate mental health staffing and psychiatric referral provision
    Part of recurring concern: Insufficient mental health service capacity for timely patient care
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.12

  1. Action

    Issue a Governor’s Order defining staff responsibility and accountability for ACCT documents.

    Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 13 June 2016.
  2. Action

    Introduce an additional weekly ACCT document check by a Custodial Manager.

    Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 13 June 2016.
  3. Action

    Require staff to notify Safer Custody of prisoner concerns so an immediate ACCT review is organised, with escalation when responsible staff are unavailable.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 13 June 2016.

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

  1. Position

    Operational issues concerning proper observance of ACCT procedures should be addressed by NOMS.

    Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking 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 provide specialist hospital treatment for serious mental illness

Wider context from the report

“The seriousness of the deceased’s condition was realised whilst the deceased was at HMP Durham although probably initially misdiagnosed. During a hyponamic episode which lasted a number of weeks the deceased was for a time left in a urine soaked cell, drinking and washing from the cell toilet at a time when he needed specialist hospital treatment. The evidence showed that his illness was not properly addressed. At HMP Durham a psychiatric referral for the purpose of compiling a care plan, including a plan for therapeutic medication was never completed and he was transferred to HMP Haverigg without any steps being taken to plan health care for the future, take action to avoid a recurrence of his illness or identify and deal with a relapse should one occur. At HMP Haverigg there was inadequate mental health cover with at times only one mental health nurse and no provision for psychiatric referral. He was transferred to HMP Kirkham. A lack of suitable psychiatric care facilities at HMP Kirkham (among other things) led to a transfer to HMP Risley, where due to inadequacies of care planning and communication deficits which had been a feature of the deceased’s care whilst in prison, the fact that the deceased was relapsing into depression was not recognised. The jury concluded that the deceased’s death by hanging was partly due to deficiencies in mental health care and failure to properly observe ACCT procedures. ”

Is this part of a recurring concern?

Yes — Unreliable access to specialist mental health treatment for serious mental illness.

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

Inadequacies in mental health care planning and communication

Wider context from the report

“The seriousness of the deceased’s condition was realised whilst the deceased was at HMP Durham although probably initially misdiagnosed. During a hyponamic episode which lasted a number of weeks the deceased was for a time left in a urine soaked cell, drinking and washing from the cell toilet at a time when he needed specialist hospital treatment. The evidence showed that his illness was not properly addressed. At HMP Durham a psychiatric referral for the purpose of compiling a care plan, including a plan for therapeutic medication was never completed and he was transferred to HMP Haverigg without any steps being taken to plan health care for the future, take action to avoid a recurrence of his illness or identify and deal with a relapse should one occur. At HMP Haverigg there was inadequate mental health cover with at times only one mental health nurse and no provision for psychiatric referral. He was transferred to HMP Kirkham. A lack of suitable psychiatric care facilities at HMP Kirkham (among other things) led to a transfer to HMP Risley, where due to inadequacies of care planning and communication deficits which had been a feature of the deceased’s care whilst in prison, the fact that the deceased was relapsing into depression was not recognised. The jury concluded that the deceased’s death by hanging was partly due to deficiencies in mental health care and failure to properly observe ACCT procedures. ”

Is this part of a recurring concern?

Yes — Failure to integrate mental health services across care settings; Failure to provide continuity of patient care.

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 mental health staffing and psychiatric referral provision

Wider context from the report

“The seriousness of the deceased’s condition was realised whilst the deceased was at HMP Durham although probably initially misdiagnosed. During a hyponamic episode which lasted a number of weeks the deceased was for a time left in a urine soaked cell, drinking and washing from the cell toilet at a time when he needed specialist hospital treatment. The evidence showed that his illness was not properly addressed. At HMP Durham a psychiatric referral for the purpose of compiling a care plan, including a plan for therapeutic medication was never completed and he was transferred to HMP Haverigg without any steps being taken to plan health care for the future, take action to avoid a recurrence of his illness or identify and deal with a relapse should one occur. At HMP Haverigg there was inadequate mental health cover with at times only one mental health nurse and no provision for psychiatric referral. He was transferred to HMP Kirkham. A lack of suitable psychiatric care facilities at HMP Kirkham (among other things) led to a transfer to HMP Risley, where due to inadequacies of care planning and communication deficits which had been a feature of the deceased’s care whilst in prison, the fact that the deceased was relapsing into depression was not recognised. The jury concluded that the deceased’s death by hanging was partly due to deficiencies in mental health care and failure to properly observe ACCT procedures. ”

Is this part of a recurring concern?

Yes — Insufficient mental health service capacity for timely patient care.

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 recognise relapse into depression

Wider context from the report

“The seriousness of the deceased’s condition was realised whilst the deceased was at HMP Durham although probably initially misdiagnosed. During a hyponamic episode which lasted a number of weeks the deceased was for a time left in a urine soaked cell, drinking and washing from the cell toilet at a time when he needed specialist hospital treatment. The evidence showed that his illness was not properly addressed. At HMP Durham a psychiatric referral for the purpose of compiling a care plan, including a plan for therapeutic medication was never completed and he was transferred to HMP Haverigg without any steps being taken to plan health care for the future, take action to avoid a recurrence of his illness or identify and deal with a relapse should one occur. At HMP Haverigg there was inadequate mental health cover with at times only one mental health nurse and no provision for psychiatric referral. He was transferred to HMP Kirkham. A lack of suitable psychiatric care facilities at HMP Kirkham (among other things) led to a transfer to HMP Risley, where due to inadequacies of care planning and communication deficits which had been a feature of the deceased’s care whilst in prison, the fact that the deceased was relapsing into depression was not recognised. The jury concluded that the deceased’s death by hanging was partly due to deficiencies in mental health care and failure to properly observe ACCT procedures. ”

Is this part of a recurring concern?

Yes — Failure to recognise and respond to deteriorating mental health in service users.

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 properly observe ACCT procedures

Wider context from the report

“The seriousness of the deceased’s condition was realised whilst the deceased was at HMP Durham although probably initially misdiagnosed. During a hyponamic episode which lasted a number of weeks the deceased was for a time left in a urine soaked cell, drinking and washing from the cell toilet at a time when he needed specialist hospital treatment. The evidence showed that his illness was not properly addressed. At HMP Durham a psychiatric referral for the purpose of compiling a care plan, including a plan for therapeutic medication was never completed and he was transferred to HMP Haverigg without any steps being taken to plan health care for the future, take action to avoid a recurrence of his illness or identify and deal with a relapse should one occur. At HMP Haverigg there was inadequate mental health cover with at times only one mental health nurse and no provision for psychiatric referral. He was transferred to HMP Kirkham. A lack of suitable psychiatric care facilities at HMP Kirkham (among other things) led to a transfer to HMP Risley, where due to inadequacies of care planning and communication deficits which had been a feature of the deceased’s care whilst in prison, the fact that the deceased was relapsing into depression was not recognised. The jury concluded that the deceased’s death by hanging was partly due to deficiencies in mental health care and failure to properly observe ACCT procedures. ”

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

Lack of suitable psychiatric care facilities

Wider context from the report

“The seriousness of the deceased’s condition was realised whilst the deceased was at HMP Durham although probably initially misdiagnosed. During a hyponamic episode which lasted a number of weeks the deceased was for a time left in a urine soaked cell, drinking and washing from the cell toilet at a time when he needed specialist hospital treatment. The evidence showed that his illness was not properly addressed. At HMP Durham a psychiatric referral for the purpose of compiling a care plan, including a plan for therapeutic medication was never completed and he was transferred to HMP Haverigg without any steps being taken to plan health care for the future, take action to avoid a recurrence of his illness or identify and deal with a relapse should one occur. At HMP Haverigg there was inadequate mental health cover with at times only one mental health nurse and no provision for psychiatric referral. He was transferred to HMP Kirkham. A lack of suitable psychiatric care facilities at HMP Kirkham (among other things) led to a transfer to HMP Risley, where due to inadequacies of care planning and communication deficits which had been a feature of the deceased’s care whilst in prison, the fact that the deceased was relapsing into depression was not recognised. The jury concluded that the deceased’s death by hanging was partly due to deficiencies in mental health care and failure to properly observe ACCT procedures. ”

Is this part of a recurring concern?

Yes — Inadequate care and supervision provision for prisoners with complex needs; Insufficient mental health service capacity for timely patient care.

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 plan ongoing mental health care and relapse management

Wider context from the report

“The seriousness of the deceased’s condition was realised whilst the deceased was at HMP Durham although probably initially misdiagnosed. During a hyponamic episode which lasted a number of weeks the deceased was for a time left in a urine soaked cell, drinking and washing from the cell toilet at a time when he needed specialist hospital treatment. The evidence showed that his illness was not properly addressed. At HMP Durham a psychiatric referral for the purpose of compiling a care plan, including a plan for therapeutic medication was never completed and he was transferred to HMP Haverigg without any steps being taken to plan health care for the future, take action to avoid a recurrence of his illness or identify and deal with a relapse should one occur. At HMP Haverigg there was inadequate mental health cover with at times only one mental health nurse and no provision for psychiatric referral. He was transferred to HMP Kirkham. A lack of suitable psychiatric care facilities at HMP Kirkham (among other things) led to a transfer to HMP Risley, where due to inadequacies of care planning and communication deficits which had been a feature of the deceased’s care whilst in prison, the fact that the deceased was relapsing into depression was not recognised. The jury concluded that the deceased’s death by hanging was partly due to deficiencies in mental health care and failure to properly observe ACCT procedures. ”

Is this part of a recurring concern?

Yes — Failure to recognise and respond to deteriorating mental health in service users.

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 complete psychiatric referral and therapeutic medication care planning

Wider context from the report

“The seriousness of the deceased’s condition was realised whilst the deceased was at HMP Durham although probably initially misdiagnosed. During a hyponamic episode which lasted a number of weeks the deceased was for a time left in a urine soaked cell, drinking and washing from the cell toilet at a time when he needed specialist hospital treatment. The evidence showed that his illness was not properly addressed. At HMP Durham a psychiatric referral for the purpose of compiling a care plan, including a plan for therapeutic medication was never completed and he was transferred to HMP Haverigg without any steps being taken to plan health care for the future, take action to avoid a recurrence of his illness or identify and deal with a relapse should one occur. At HMP Haverigg there was inadequate mental health cover with at times only one mental health nurse and no provision for psychiatric referral. He was transferred to HMP Kirkham. A lack of suitable psychiatric care facilities at HMP Kirkham (among other things) led to a transfer to HMP Risley, where due to inadequacies of care planning and communication deficits which had been a feature of the deceased’s care whilst in prison, the fact that the deceased was relapsing into depression was not recognised. The jury concluded that the deceased’s death by hanging was partly due to deficiencies in mental health care and failure to properly observe ACCT procedures. ”

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

Issue a Governor’s Order defining staff responsibility and accountability for ACCT documents.

Verbatim wording from the response

“A Governor’s Order will be issued setting out clearly which member of staff is responsible for which ACCT documents at what time, encouraging personal ownership and ensuring accountability. Staff who have not completed an ACCT document satisfactorily will be asked to account for their actions and, where necessary, action will be escalated through a verbal warning, written warning or investigation for misconduct as appropriate. In support of this, all Offender Supervisors and Custodial Managers are being briefed about the importance of the ACCT process.”

Source location

2016-0220-Response-by-NOMS
Page 1 · response
Published 13 June 2016

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 an additional weekly ACCT document check by a Custodial Manager.

Verbatim wording from the response

“The level and depth of management checks on the ACCT process have been increased. All ACCT documents are checked daily by Officer Supervisors, and an additional weekly check by a Custodial Manager is being introduced. The Head of Safer Custody will also be checking a sample of ACCT documents each week, and will continue to do so until he is satisfied that the standards have improved and that the relevant processes are embedded.”

Source location

2016-0220-Response-by-NOMS
Page 1 · response
Published 13 June 2016

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

Require staff to notify Safer Custody of prisoner concerns so an immediate ACCT review is organised, with escalation when responsible staff are unavailable.

Verbatim wording from the response

“In order to ensure that any concerns that are raised about a prisoner are being acted upon, staff have been informed that they must contact the Safer Custody department, who will organise an immediate ACCT review for that day. If the named Offender Supervisor cannot attend it will be escalated to the “Oscar” group (comprised of three Offender Supervisors), and where they are not available it will be further escalated to the duty Custodial Manager (who is available 24 hours).”

Source location

2016-0220-Response-by-NOMS
Page 1 · response
Published 13 June 2016

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

Check all ACCT documents daily through Officer Supervisors.

Verbatim wording from the response

“The level and depth of management checks on the ACCT process have been increased. All ACCT documents are checked daily by Officer Supervisors, and an additional weekly check by a Custodial Manager is being introduced. The Head of Safer Custody will also be checking a sample of ACCT documents each week, and will continue to do so until he is satisfied that the standards have improved and that the relevant processes are embedded.”

Source location

2016-0220-Response-by-NOMS
Page 1 · response
Published 13 June 2016

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

Brief all Offender Supervisors and Custodial Managers on the importance of the ACCT process.

Verbatim wording from the response

“A Governor’s Order will be issued setting out clearly which member of staff is responsible for which ACCT documents at what time, encouraging personal ownership and ensuring accountability. Staff who have not completed an ACCT document satisfactorily will be asked to account for their actions and, where necessary, action will be escalated through a verbal warning, written warning or investigation for misconduct as appropriate. In support of this, all Offender Supervisors and Custodial Managers are being briefed about the importance of the ACCT process.”

Source location

2016-0220-Response-by-NOMS
Page 1 · response
Published 13 June 2016

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

Require staff to account for unsatisfactory ACCT documents and escalate appropriate cases through warnings or misconduct investigation.

Verbatim wording from the response

“A Governor’s Order will be issued setting out clearly which member of staff is responsible for which ACCT documents at what time, encouraging personal ownership and ensuring accountability. Staff who have not completed an ACCT document satisfactorily will be asked to account for their actions and, where necessary, action will be escalated through a verbal warning, written warning or investigation for misconduct as appropriate. In support of this, all Offender Supervisors and Custodial Managers are being briefed about the importance of the ACCT process.”

Source location

2016-0220-Response-by-NOMS
Page 1 · response
Published 13 June 2016

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

Conduct weekly sample checks of ACCT documents until standards improve and processes are embedded.

Verbatim wording from the response

“The level and depth of management checks on the ACCT process have been increased. All ACCT documents are checked daily by Officer Supervisors, and an additional weekly check by a Custodial Manager is being introduced. The Head of Safer Custody will also be checking a sample of ACCT documents each week, and will continue to do so until he is satisfied that the standards have improved and that the relevant processes are embedded.”

Source location

2016-0220-Response-by-NOMS
Page 1 · response
Published 13 June 2016

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

Complete consultation and publish the updated guidance for transferring prisoners to and from secure mental-health hospitals.

Verbatim wording from the response

“secure mental health hospitals. This guidance is due for final consultation in autumn 2016 prior to publication and until the Department of Health 2011 guidelines remain extant. The HJIPs data set also contains transfer timelines to mental health secure units.”

Source location

2016-0220-Response-by-NHS-England
Page 3 · response
Published 13 June 2016

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

Maintain nationally specified integrated stepped mental-health care, including consultant psychiatry, long-term care planning and continuity of care.

Verbatim wording from the response

“Better integration of health care services within prisons has also been supported by the development of a national set of service specifications for primary care services (including GP and nursing services), mental health services and substance misuse services. The mental health service specification outlines the requirement for mental health services to provide an integrated stepped care model for mental health which enables patients to flow seamlessly between mild to moderate and severe and enduring stages based on clinical need and include the provision of a consultant psychiatrist. These service specifications were developed in December 2013 and set the outcomes and standards required from the services including long-term care planning and continuity of care.”

Source location

2016-0220-Response-by-NHS-England
Page 2 · response
Published 13 June 2016

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

Develop updated guidance for transferring prisoners to and from secure mental-health hospitals.

Verbatim wording from the response

“NHS England Health and Justice and Specialised Commissioning teams have developed updated guidelines for the transfer of prisoners to and remission from”

Source location

2016-0220-Response-by-NHS-England
Page 2 · response
Published 13 June 2016

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

Roll out the revised Person Escort Record and provide training so operational staff transfer relevant health information throughout custody transitions.

Verbatim wording from the response

“NHS England is supporting the National Offender Management Services (NOMS) with their review of the Person Escort Record (PER). This revised form ensures that all current and relevant information, including health information, is held in one document and transfers with the prisoner from police custody through to reception into prison and during any subsequent prison transfer or release. The roll out of the paper form pilot is still ongoing and work is being undertaken to ensure PER training will be available to all operational staff. This is expected to be launched by March 2017. The digital PER form is being piloted in a couple of prisons and NOMS are leading on this work.”

Source location

2016-0220-Response-by-NHS-England
Page 2 · response
Published 13 June 2016

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

Work with specialised commissioning teams and partner organisations to address the shortage of secure psychiatric beds and delays transferring acutely unwell prisoners.

Verbatim wording from the response

“NHS England recognises that there is a national issue regarding lack of secure psychiatric beds which impacts on the timely transfer of acutely unwell prisoners. The Health and Justice commissioning team are working with colleagues in the NHS England Specialised Commissioning teams, who are responsible for secure mental health provision, and other partners in Department of Health, National Offender Management Services and Ministry of Justice and Home Office to look at this issue and try to resolve it.”

Source location

2016-0220-Response-by-NHS-England
Page 2 · response
Published 13 June 2016

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 issues concerning proper observance of ACCT procedures should be addressed by NOMS.

Verbatim wording from the response

“The specific issues you raise about the failure to properly observe Assessment, Care in Custody & Teamwork (ACCT) procedures are operational and should be addressed by NOMS.”

Source location

2016-0220-Response-by-Department-of-Health
Page 2 · response
Published 13 June 2016

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

Specialised Commissioning teams are responsible for secure mental health provision, including addressing shortages affecting transfers of acutely unwell prisoners.

Verbatim wording from the response

“NHS England recognises that there is a national issue regarding lack of secure psychiatric beds which impacts on the timely transfer of acutely unwell prisoners. The Health and Justice commissioning team are working with colleagues in the NHS England Specialised Commissioning teams, who are responsible for secure mental health provision, and other partners in Department of Health, National Offender Management Services and Ministry of Justice and Home Office to look at this issue and try to resolve it.”

Source location

2016-0220-Response-by-NHS-England
Page 2 · response
Published 13 June 2016

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.3

  1. 1

    Work with NOMS and NHS England to improve the safety and quality of prison physical and mental health services.

    Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 13 June 2016.
  2. 2

    Collect and formally report Health and Justice Indicators of Performance data, including mental-health service outcomes, through quarterly contract meetings.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 13 June 2016.
  3. 3

    Review mental-health and substance-misuse service specifications to incorporate needs assessments and lessons from deaths in custody.

    Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 13 June 2016.

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

Work with NOMS and NHS England to improve the safety and quality of prison physical and mental health services.

Verbatim wording from the response

“The safety and wellbeing of prisoners should be paramount which includes delivering high quality physical and mental health services that meet the needs of prisoners. The Department of Health is committed to working with the National Offender Management Service (NOMS) and NHS England, as the commissioner of health and justice services, to ensure that this happens. However, you have highlighted issues relating to Mr Dermott’s care that demonstrate there is much more we need to do.”

Source location

2016-0220-Response-by-Department-of-Health
Page 1 · response
Published 13 June 2016

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

Collect and formally report Health and Justice Indicators of Performance data, including mental-health service outcomes, through quarterly contract meetings.

Verbatim wording from the response

“During the financial year of 2014/15, a new data set in health & justice called ‘The Health & Justice Indicators of Performance’ (HJIPs) was introduced. The data set collects information on the delivery and outcome requirements NHS England are required to commission as part of their organisational responsibilities and includes outcomes data on mental health service provision. Formal reporting of this data commenced on 1 April 2016 with the first quarterly data due to be submitted to NHS England in July 2016. This data forms part of the quarterly contract meetings between the regional health and justice commissioners and the prime providers.”

Source location

2016-0220-Response-by-NHS-England
Page 2 · response
Published 13 June 2016

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 mental-health and substance-misuse service specifications to incorporate needs assessments and lessons from deaths in custody.

Verbatim wording from the response

“A planned review of the specifications is underway to respond to the Health and Well-Being Needs Assessments with substance misuse specification and mental health services for immigration removal centres underway and expected to be completed by the end of 2016. The review of the prison mental health specification will also align to the Ministry of Justice review of mental health in prisons as part of the prison reform agenda of which a date is to be set to commence the work. This will provide NHS England with an opportunity to ensure lessons learnt from deaths in custody inform our commissioning responsibilities.”

Source location

2016-0220-Response-by-NHS-England
Page 2 · response
Published 13 June 2016

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