PFD report

Alan George Stead · Prevention of Future Deaths report

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Issued 22 Jul 2016•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
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
4

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 raised2

  1. Delays in testing blood samples from prisoners
    Part of recurring concern: Failure to provide timely clinically required blood tests
  2. Delays in taking blood samples from 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

    Send blood samples to the hospital laboratory each afternoon on the day they are taken.

    Stated by Care UKStated completedThe respondent said that this action was complete when they made their response on 22 July 2016.
  2. Action

    Conduct required blood tests promptly, using same-day testing where possible and a short waiting list when same-day testing is unavailable.

    Stated by Care UKStated completedThe respondent said that this action was complete when they made their response on 22 July 2016.
  3. Action

    Train and competency-sign off all nurses and healthcare assistants in phlebotomy at HMP Dovegate.

    Stated by Care UKStated completedThe respondent said that this action was complete when they made their response on 22 July 2016.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    The delayed blood test would not have affected Mr Stead’s death or resulted in different treatment.

    Stated by Care UKDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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

Delays in testing blood samples from prisoners

Wider context from the report

“(1) The medical review has identified delays with the taking and testing of blood samples from prisoners at HMP Dovegate. This was not something included in a recommendation in the PPO report but was expressed as a concern by the family at the Inquest. This could have serious consequences in some cases. I wonder if you have looked at this and have done or can do anything to improve the situation with this at HMP Dovegate and indeed at any other prisons where you provide healthcare if this is an issue. ”

Is this part of a recurring concern?

Yes — Failure to provide timely clinically required blood tests.

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

Delays in taking blood samples from prisoners

Wider context from the report

“(1) The medical review has identified delays with the taking and testing of blood samples from prisoners at HMP Dovegate. This was not something included in a recommendation in the PPO report but was expressed as a concern by the family at the Inquest. This could have serious consequences in some cases. I wonder if you have looked at this and have done or can do anything to improve the situation with this at HMP Dovegate and indeed at any other prisons where you provide healthcare if this is an issue. ”

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

Send blood samples to the hospital laboratory each afternoon on the day they are taken.

Verbatim wording from the response

“On 14 December 2015 a programme was introduced at HMP Dovegate for all nurses and HCAs to be trained in phlebotomy. This programme was completed and all of the staff were deemed competent and signed off in March 2016. Now, blood tests are conducted as soon as required and on the same day whenever possible or if flagged urgent. If they are not performed on the day, patients are added onto a waiting list of a few days. Blood samples are sent to the hospital laboratory the day each afternoon.”

Source location

2016-0261-Response-by-Care-UK
Page 2 · response
Published 22 July 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

Conduct required blood tests promptly, using same-day testing where possible and a short waiting list when same-day testing is unavailable.

Verbatim wording from the response

“On 14 December 2015 a programme was introduced at HMP Dovegate for all nurses and HCAs to be trained in phlebotomy. This programme was completed and all of the staff were deemed competent and signed off in March 2016. Now, blood tests are conducted as soon as required and on the same day whenever possible or if flagged urgent. If they are not performed on the day, patients are added onto a waiting list of a few days. Blood samples are sent to the hospital laboratory the day each afternoon.”

Source location

2016-0261-Response-by-Care-UK
Page 2 · response
Published 22 July 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

Train and competency-sign off all nurses and healthcare assistants in phlebotomy at HMP Dovegate.

Verbatim wording from the response

“On 14 December 2015 a programme was introduced at HMP Dovegate for all nurses and HCAs to be trained in phlebotomy. This programme was completed and all of the staff were deemed competent and signed off in March 2016. Now, blood tests are conducted as soon as required and on the same day whenever possible or if flagged urgent. If they are not performed on the day, patients are added onto a waiting list of a few days. Blood samples are sent to the hospital laboratory the day each afternoon.”

Source location

2016-0261-Response-by-Care-UK
Page 2 · response
Published 22 July 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

The delayed blood test would not have affected Mr Stead’s death or resulted in different treatment.

Verbatim wording from the response

“As noted by the independent clinical reviewer, this blood test would not have had an impact on Mr Stead’s death on 21 January and an earlier test would not have resulted in Mr Stead receiving any different treatment.”

Source location

2016-0261-Response-by-Care-UK
Page 2 · response
Published 22 July 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.1

  1. 1

    Share events and learning from Mr Stead’s death with all Regional Managers through the National Quality and Improvement Meeting.

    Stated by Care UKStated completedThe respondent said that this action was complete when they made their response on 22 July 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

Share events and learning from Mr Stead’s death with all Regional Managers through the National Quality and Improvement Meeting.

Verbatim wording from the response

“More widely, the Governance team have shared the events and learning from Mr Stead’s death as part of the National Quality and Improvement Meeting for all Regional Managers.”

Source location

2016-0261-Response-by-Care-UK
Page 2 · response
Published 22 July 2016

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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