PFD report

Matthew Colin SARGENT · Prevention of Future Deaths report

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Issued 7 Apr 2016•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.

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Concerns
4

Raised in this report

Recipients
2

Named on the report

Responses found
2

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 raised4

  1. Failure to inform Healthcare staff when prisoners arrive with an ACCT history
    Part of recurring concern: Inadequate prison reception safeguardsPart of recurring concern: Unreliable ACCT suicide and self-harm prevention processesPart of recurring concern: Unsafe interoperability between prison custody and healthcare procedures
  2. Failure to review available historical prisoner information at initial presentation
    Part of recurring concern: Inadequate prison reception safeguards
  3. Lack of meaningful engagement between Personal Officers and individual 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.6

  1. Action

    Remind staff of the Personal Officer policy through a Safer Custody Bulletin and Custodial Manager dissemination.

    Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 7 April 2016.
  2. Action

    Record monthly Personal Officer scheme management and case-note checks on P-NOMIS.

    Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 7 April 2016.
  3. Action

    Remind prison and healthcare staff to check the PER every time and escalate unavailable records through a Datix incident report.

    Stated by Practice Plus Group Hospitals LimitedStated completedThe respondent said that this action was complete when they made their response on 7 April 2016.

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

  1. Position

    Personal Officer roles and regular prisoner meetings fall within the Prison Service’s remit, not the healthcare provider’s functions.

    Stated by Practice Plus Group Hospitals LimitedOutside remitThe respondent said that this matter was outside its role or authority.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to inform Healthcare staff when prisoners arrive with an ACCT history

Wider context from the report

“(3) There was a concern that Healthcare staff were not made aware of prisoners who arrive with an ACCT history and it was suggested that Healthcare should be informed in all cases where a prisoner arrives at reception with an ACCT history so that there is a continued sharing of pertinent information. ”

Is this part of a recurring concern?

Yes — Inadequate prison reception safeguards; Unreliable ACCT suicide and self-harm prevention processes; 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 review available historical prisoner information at initial presentation

Wider context from the report

“(2) There was a concern that historical information which was available to Officers and Healthcare staff was not reviewed when the prisoner first presented at the prison and it was suggested that it would be beneficial if there was an instruction that any member of staff dealing with a prisoner who had access to historical information should make some enquiry as to that historical information so as to inform them of both the present and past risks. ”

Is this part of a recurring concern?

Yes — Inadequate prison reception safeguards.

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 meaningful engagement between Personal Officers and individual prisoners

Wider context from the report

“(1) The Personal Officer of Mr Sargent appeared to have had little to do with him. It was suggested that there should regular meetings between Personal Officers and individual prisoners so that a more indepth knowledge of individual prisoners could be obtained as shared. ”

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 supply Prisoner Escort Records to Healthcare staff at reception

Wider context from the report

“(4) There was a concern that the Prisoner Escort Record (highlighting concerns and risks) was not supplied to the Healthcare Department and nurses at reception. It was suggested that this should be an imperative requirement for the further sharing of relevant information. ”

Is this part of a recurring concern?

Yes — Inadequate prison reception safeguards; Unreliable completion and transfer of Prisoner Escort Records; Unsafe interoperability between prison custody and healthcare procedures.

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

Remind staff of the Personal Officer policy through a Safer Custody Bulletin and Custodial Manager dissemination.

Verbatim wording from the response

“Following your concerns regarding the operation of the Personal Officer scheme at HMP Long Lartin the prison will ensure that all staff are reminded of the policy. This will be achieved through a range of communications with staff including the issuing of a Safer Custody Bulletin and dissemination through Custodial Managers.”

Source location

NOMS-Response_Redacted
Page 1 · response
Published 7 April 2016

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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

Record monthly Personal Officer scheme management and case-note checks on P-NOMIS.

Verbatim wording from the response

“The effectiveness of the Personal Officer scheme is monitored on a monthly basis, with Supervising Officers checking all case-note entries and ensuring that support officers are in place. Custodial Managers also carry out quality checks on both management checks and case-note checks. This is completed monthly and these checks will be recorded on P-NOMIS.”

Source location

NOMS-Response_Redacted
Page 1 · response
Published 7 April 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

Remind prison and healthcare staff to check the PER every time and escalate unavailable records through a Datix incident report.

Verbatim wording from the response

“In order to ensure robust communication and partnership working going forward we will continue to work closely with our prison partners on this and in particular, the Head of Healthcare is working to address the concern with the Safer Custody Governor. In addition, all (prison and healthcare) staff have been reminded that they must see the PER on every occasion and that non-access should be escalated within the prison via a datix incident report. If the staff member does not have access, an incident form should be completed as soon as it is apparent that a PER isn’t available.”

Source location

Matthew-Sargent-Response
Page 3 · response
Published 7 April 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 the reception screening process to develop a standard first-reception screening template across prison healthcare settings.

Verbatim wording from the response

“As stated above, Care UK was not the healthcare provider at HMP Long Lartin at the time of Mr Sargent’s death. Going forward, the Care UK suicide prevention strategy will be shared and rolled out across all sites. In addition, since taking over healthcare responsibility on 1 April 2016, Care UK plans to review the reception screening process to introduce a standard template for first reception screening across its prison healthcare settings. We are also looking at the process of information gathering on reception and the culture around this. We will expect staff to ask ‘Where is the information for this patient?’ and the SystemOne template will reflect this, ensuring that staff cannot proceed without seeking out the information and recording reasons why, in instances where the information is not available.”

Source location

Matthew-Sargent-Response
Page 2 · response
Published 7 April 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

Update the SystemOne reception template to require staff to seek available information and record reasons when it is unavailable.

Verbatim wording from the response

“As stated above, Care UK was not the healthcare provider at HMP Long Lartin at the time of Mr Sargent’s death. Going forward, the Care UK suicide prevention strategy will be shared and rolled out across all sites. In addition, since taking over healthcare responsibility on 1 April 2016, Care UK plans to review the reception screening process to introduce a standard template for first reception screening across its prison healthcare settings. We are also looking at the process of information gathering on reception and the culture around this. We will expect staff to ask ‘Where is the information for this patient?’ and the SystemOne template will reflect this, ensuring that staff cannot proceed without seeking out the information and recording reasons why, in instances where the information is not available.”

Source location

Matthew-Sargent-Response
Page 2 · response
Published 7 April 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

Ensure reception information-gathering processes are clear and effective.

Verbatim wording from the response

“We will ensure our processes for obtaining information on reception are clear and effective and build relationships with local community providers to improve information flow. Furthermore, we will record lack of information at reception on our incident system so that we understand the extent of the issues and can monitor trends and share good practice. We recognise that we cannot rely solely on the first night reception and that on-going assessment over several days is essential in order to ensure we are aware of any changing clinical picture and to take account of any new information that arrives.”

Source location

Matthew-Sargent-Response
Page 2 · response
Published 7 April 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

Personal Officer roles and regular prisoner meetings fall within the Prison Service’s remit, not the healthcare provider’s functions.

Verbatim wording from the response

“The role and responsibilities of Personal Officers fall within the remit of the Prison Service and not the Healthcare Provider. Care UK is therefore unable to comment on this but trusts that the Government Legal Department will respond on behalf of the MoJ.”

Source location

Matthew-Sargent-Response
Page 1 · response
Published 7 April 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

Prison Service staff are responsible for examining and sharing PER and ACCT information with healthcare staff.

Verbatim wording from the response

“These two points raise similar issues and can be answered together. It is the responsibility of prison service staff to share information with other departments and agencies both internal and external. PSI 74/2011 (First Days in Custody) sets out the requirement for the Person Escort Record (PER) form to be examined in Reception by prison staff to identify any immediate needs and risks and for this information to be forwarded to other staff and agencies as necessary, including healthcare. PSI 74/2011 sets out the mandatory requirements for prison staff and healthcare in respect of a prisoner’s ACCT status, ACCT alerts and risk assessments. Care UK thus expects PSI 74/2011 to be followed and that prison personnel will record a prisoner’s ACCT status on their record and share this and any concerns with Healthcare.”

Source location

Matthew-Sargent-Response
Page 3 · response
Published 7 April 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.9

  1. 1

    Send first-night induction paperwork to Healthcare with the Prisoner Escort Record after completion.

    Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 7 April 2016.
  2. 2

    Notify Healthcare by telephone when a new prisoner with an ACCT history arrives at Long Lartin.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 7 April 2016.
  3. 3

    Disseminate historical risk indicators from pre-transfer reports to Healthcare, Reception and the Safer Prisons team.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 7 April 2016.
  4. 4

    Copy the Prisoner Escort Record and take it to Healthcare with the prisoner.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 7 April 2016.
  5. 5

    Record missing reception information on the incident system to monitor trends and share good practice.

    Stated by Practice Plus Group Hospitals LimitedStated plannedThe respondent said that this action was planned when they made their response on 7 April 2016.
  6. 6

    Continue discussions with prison colleagues to review communication pathways between prison and healthcare services.

    Stated by Practice Plus Group Hospitals LimitedStated in progressThe respondent said that this action was in progress when they made their response on 7 April 2016.
  7. 7

    Continue working with prison partners, including the Safer Custody Governor, to address communication concerns.

    Stated by Practice Plus Group Hospitals LimitedStated in progressThe respondent said that this action was in progress when they made their response on 7 April 2016.
  8. 8

    Build relationships with local community providers to improve information flow.

    Stated by Practice Plus Group Hospitals LimitedStated plannedThe respondent said that this action was planned when they made their response on 7 April 2016.
  9. 9

    Share and roll out the Care UK suicide prevention strategy across all sites.

    Stated by Practice Plus Group Hospitals LimitedStated plannedThe respondent said that this action was planned when they made their response on 7 April 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

Send first-night induction paperwork to Healthcare with the Prisoner Escort Record after completion.

Verbatim wording from the response

“Following this, Healthcare will also receive a copy of the first night induction paperwork, which is completed with the prisoner and gives details of any ACCT history. This documentation is sent with the prisoner as part of the Prisoner Escort Record (PER) when they attend Healthcare, ensuring that any information regarding relevant issues are available to staff.”

Source location

NOMS-Response_Redacted
Page 2 · response
Published 7 April 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

Notify Healthcare by telephone when a new prisoner with an ACCT history arrives at Long Lartin.

Verbatim wording from the response

“Consideration has been given as to how to ensure Healthcare staff are made aware of prisoners who arrive with an ACCT history, and action taken to resolve this. It is now the case that when a new prisoner who has an ACCT history is received into Long Lartin, reception staff notify healthcare by phone in the first instance.”

Source location

NOMS-Response_Redacted
Page 2 · response
Published 7 April 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

Disseminate historical risk indicators from pre-transfer reports to Healthcare, Reception and the Safer Prisons team.

Verbatim wording from the response

“I can confirm that in response to this concern, a process has been put in place to ensure that staff gain access to historical information where this information is available. Officer Management Unit staff are now responsible for ensuring that historical risk indicators are disseminated to Healthcare, Reception and the Safer Prisons team. This information is drawn from the pre-transfer report (a document which includes all the prisoner's details including ACCT information and case notes), which is sent to the receiving establishment before a prisoner is transferred.”

Source location

NOMS-Response_Redacted
Page 2 · response
Published 7 April 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

Copy the Prisoner Escort Record and take it to Healthcare with the prisoner.

Verbatim wording from the response

“On completion of Mr Sargent's inquest a new process was implemented in the reception department whereby the PER form is now copied and taken to the healthcare department with the prisoner.”

Source location

NOMS-Response_Redacted
Page 2 · response
Published 7 April 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

Record missing reception information on the incident system to monitor trends and share good practice.

Verbatim wording from the response

“We will ensure our processes for obtaining information on reception are clear and effective and build relationships with local community providers to improve information flow. Furthermore, we will record lack of information at reception on our incident system so that we understand the extent of the issues and can monitor trends and share good practice. We recognise that we cannot rely solely on the first night reception and that on-going assessment over several days is essential in order to ensure we are aware of any changing clinical picture and to take account of any new information that arrives.”

Source location

Matthew-Sargent-Response
Page 2 · response
Published 7 April 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

Continue discussions with prison colleagues to review communication pathways between prison and healthcare services.

Verbatim wording from the response

“Since the death of Mr Sargent, discussions have been held with Prison colleagues to review communication pathways between the Prison and Healthcare Services. These discussions are on-going.”

Source location

Matthew-Sargent-Response
Page 2 · response
Published 7 April 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

Continue working with prison partners, including the Safer Custody Governor, to address communication concerns.

Verbatim wording from the response

“In order to ensure robust communication and partnership working going forward we will continue to work closely with our prison partners on this and in particular, the Head of Healthcare is working to address the concern with the Safer Custody Governor. In addition, all (prison and healthcare) staff have been reminded that they must see the PER on every occasion and that non-access should be escalated within the prison via a datix incident report. If the staff member does not have access, an incident form should be completed as soon as it is apparent that a PER isn’t available.”

Source location

Matthew-Sargent-Response
Page 3 · response
Published 7 April 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

Build relationships with local community providers to improve information flow.

Verbatim wording from the response

“We will ensure our processes for obtaining information on reception are clear and effective and build relationships with local community providers to improve information flow. Furthermore, we will record lack of information at reception on our incident system so that we understand the extent of the issues and can monitor trends and share good practice. We recognise that we cannot rely solely on the first night reception and that on-going assessment over several days is essential in order to ensure we are aware of any changing clinical picture and to take account of any new information that arrives.”

Source location

Matthew-Sargent-Response
Page 2 · response
Published 7 April 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

Share and roll out the Care UK suicide prevention strategy across all sites.

Verbatim wording from the response

“We recognise that early identification of risk factors and effective management of prisoners in relation to self-harm is imperative in addressing the rising incidence of suicide. The Care UK Suicide Prevention Strategy (a copy of which is attached) draws on national external and internal evidence relating to risk factors associated with suicide and provides a framework for local teams to address this vital area in their prison. A number of the measures identified in the Suicide Prevention Strategy have relevance to the concerns you have raised.”

Source location

Matthew-Sargent-Response
Page 2 · response
Published 7 April 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