PFD report

Lee Anthony Boden · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 29 Sep 2015•Milton Keynes

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
5

Raised in this report

Recipients
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
1

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 raised5

  1. Resident remaining undiscovered in bathroom for almost four hours
    Part of recurring concern: Failure to reliably supervise and monitor residents in care accommodationPart of recurring concern: Unreliable checking of prolonged occupied toilets
  2. Failure to provide timely information about intended placement
    Part of recurring concern: Unreliable communication of placement arrangements before release
  3. Increased risk of heroin use following sudden hostel arrival
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

    Address timely release planning and communication learning with managers and staff across the Buckinghamshire and Oxfordshire Local Delivery Unit.

    Stated by National Offender Management Service Directorate of ProbationStated plannedThe respondent said that this action was planned when they made their response on 29 September 2015.

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

  1. Position

    Existing walk-around, curfew and scheduled self-harm checks were considered adequate to assure residents’ well-being as far as possible.

    Stated by National Offender Management Service Directorate of ProbationExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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

Resident remaining undiscovered in bathroom for almost four hours

Wider context from the report

“(3) That he had been in the bathroom for almost four hours before he was discovered. ”

Is this part of a recurring concern?

Yes — Failure to reliably supervise and monitor residents in care accommodation; Unreliable checking of prolonged occupied toilets.

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 provide timely information about intended placement

Wider context from the report

“(1) That the deceased was not informed of his intended placement in Milton Keynes until the day before his release. ”

Is this part of a recurring concern?

Yes — Unreliable communication of placement arrangements before release.

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

Increased risk of heroin use following sudden hostel arrival

Wider context from the report

“(2) The sudden arrival at the hostel would have increased his risk of using heroin. ”

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 recognise vulnerable residents

Wider context from the report

“(4) Having just been released from prison and being unable to return to his home, he should have been recognised as a vulnerable resident. ”

Is this part of a recurring concern?

Yes — Failure to recognise vulnerability in safeguarding decisions.

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 a protocol for continuing monitoring of vulnerable new arrivals

Wider context from the report

“(5) There appears to be no protocol in place for continuing monitoring of new arrivals who remain vulnerable. ”

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

Address timely release planning and communication learning with managers and staff across the Buckinghamshire and Oxfordshire Local Delivery Unit.

Verbatim wording from the response

“In addition, rather than relying on the prison to inform Mr Boden of the change of plan, it would have been preferable for his offender manager to make contact with him to explain the circumstances and to ensure he was aware what could be done to help him on his return to the community. Timeliness in developing release plans, and ensuring that service users are kept informed of changes, are learning points for the team and this will be addressed with managers and staff across the Buckinghamshire and Oxfordshire Local Delivery Unit.”

Source location

2015-0394-Response-by-NOMS
Page 1 · response
Published 29 September 2015

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Existing walk-around, curfew and scheduled self-harm checks were considered adequate to assure residents’ well-being as far as possible.

Verbatim wording from the response

“Measures are in place to assure, as far as possible, the well-being of residents at the AP. The regime includes two “walk-around” checks during the day (the last at 5.30pm), as well as a curfew check of all residents at 11pm. Residents with earlier curfews are checked at their curfew time (as was the case with Mr Boden) and those subject to self-harm monitoring procedures are checked in accordance with a monitoring schedule set out in their self-harm management plan.”

Source location

2015-0394-Response-by-NOMS
Page 2 · response
Published 29 September 2015

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Staff could not have anticipated Mr Boden’s overdose because he showed no increased vulnerability or distress and consistently denied intending to use drugs.

Verbatim wording from the response

“Mr Boden had returned to the AP at 7pm for his curfew. He had a discussion with duty staff on his return and gave no sign of distress or other indication that his level of vulnerability had increased. The member of staff who spoke with him says that Mr Boden was pleased that he had succeeded in returning before his curfew and, while not happy about being at the AP, was positive about the prospect of discussing his situation with his offender manager the following Monday. The risk of overdose had been discussed with him at the induction interview. Both during his final weeks in custody, and again on release, Mr Boden had consistently stated that he was drug free and had no intention of using drugs. The Prisons & Probationary Ombudsman was satisfied that staff at the AP could not have anticipated Mr Boden’s actions.”

Source location

2015-0394-Response-by-NOMS
Page 2 · response
Published 29 September 2015

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

The Approved Premises had protocols for monitoring vulnerable residents, including ACCT assessments and additional checks where required.

Verbatim wording from the response

“The AP has a policy and procedures for assessing risk of self-harm and suicide and a system based on the Assessment, Care in Custody and Teamwork process (ACCT) for identifying those who require additional monitoring. In Mr Boden’s case, an ACCT assessment was undertaken and overnight welfare checks were established as a result.”

Source location

2015-0394-Response-by-NOMS
Page 2 · response
Published 29 September 2015

Open published response
Back to top

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