PFD report

WILLIAM CAMPBELL BISSETT · Prevention of Future Deaths report

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Issued 27 Jan 2025•Liverpool and the Wirral

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
3

Named on the report

Responses found
3

Of 3 recipients

Stated actions
11

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 raised5

  1. Failure to engage prisoners about accommodation when they cannot find housing
    Part of recurring concern: Failure to secure suitable accommodation for people released from prison
  2. Failure to commence accommodation planning with the relevant local authority
    Part of recurring concern: Failure to secure suitable accommodation for people released from prison
  3. Failure to inform local authorities of impending prisoner homelessness before release
    Part of recurring concern: Unreliable information sharing for prison-to-community discharge coordination
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

    Conduct a North West resettlement review and consider the consistency of multi-agency pre-release meeting arrangements within it.

    Stated by HM Prison & Probation Service, Probation Service, North WestStated in progressThe respondent said that this action was in progress when they made their response on 28 January 2025.
  2. Action

    Provide co-located or visiting local-authority housing workers to support probation staff with prison-leaver accommodation needs and referrals.

    Stated by HM Prison & Probation Service, Probation Service, North WestStated completedThe respondent said that this action was complete when they made their response on 28 January 2025.
  3. Action

    Discuss custodial cases without release addresses at multi-agency Prison Leavers Meetings using system-generated case lists and probation-led coordination.

    Stated by HM Prison & Probation Service, Probation Service, North WestStated completedThe respondent said that this action was complete when they made their response on 28 January 2025.

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

  1. Position

    Prison and Probation Service, not healthcare, is responsible for prisoner release and statutory housing referrals; healthcare provides treatment and collaborates.

    Stated by Greater Manchester Mental Health NHS Foundation TrustRedirects 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 engage prisoners about accommodation when they cannot find housing

Wider context from the report

“(2) On 23rd June 2023 Mr Bissett was informed of the terms of his licence upon release. He was informed that he would not be allowed to return home. No sufficient attempt was made to engage with Mr Bissett to discuss accommodation in the event that he was unable to find a place to live himself. ”

Is this part of a recurring concern?

Yes — Failure to secure suitable accommodation for people released from prison.

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 commence accommodation planning with the relevant local authority

Wider context from the report

“(3) 56 days before release, it being clear that Mr Bissett had nowhere to go, planning for accommodation should have been commenced with Fylde Borough Council who would have the duty to provide temporary housing and who would have engaged with Mr Bissett to discuss his requirements. ”

Is this part of a recurring concern?

Yes — Failure to secure suitable accommodation for people released from prison.

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 inform local authorities of impending prisoner homelessness before release

Wider context from the report

“(4) 56 days before release HMP Wymott should have informed the Fylde Coast Local Authorities that Mr Bissett would be homeless upon release so that his name appeared on the agenda for the monthly Prison Release Meeting. This was not done. ”

Is this part of a recurring concern?

Yes — Unreliable information sharing for prison-to-community discharge coordination.

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 arrange an early pre-release meeting with prisoners

Wider context from the report

“(1) Evidence was heard to the effect that in the 8-month period before a prisoner is released arrangements for release are the responsibility of the Community Offender Manager with the Prison Offender Manager acting as a conduit of information. Further it was said that the Community Offender Manager should arrange an early meeting with the prisoner. Mr Bissett a man aged 88 in failing health only saw his Community Offender Manager on 5th October 2023, 8 days before his release. ”

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 provide support to prisoners facing permanent separation from their spouses

Wider context from the report

“(5) Lack of planning for release and lack of engagement left Mr Bissett only with the knowledge that he would probably have to live the rest of his life separated from his wife. No attempt was made to help him come to terms with this reality. ”

Is this part of a recurring concern?

Yes — Insufficient psychological support 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

Conduct a North West resettlement review and consider the consistency of multi-agency pre-release meeting arrangements within it.

Verbatim wording from the response

“In the North West Probation Region, I have commissioned a resettlement review and the consistency of arrangements for multi-agency pre-release meetings will be considered as part of this review.”

Source location

Response from HMPPS and NW Probation Service
Page 2 · response
Published 28 January 2025

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

Provide co-located or visiting local-authority housing workers to support probation staff with prison-leaver accommodation needs and referrals.

Verbatim wording from the response

“We also have a number of PDU’s where housing workers are co-located at our offices and early indications are that this improves working relationships and the sharing of information.”

Source location

Response from HMPPS and NW Probation Service
Page 2 · response
Published 28 January 2025

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

Discuss custodial cases without release addresses at multi-agency Prison Leavers Meetings using system-generated case lists and probation-led coordination.

Verbatim wording from the response

“Locally, anyone managed by the Blackpool Probation Office in custody who is without a release address is discussed at the local Prison Leavers Meetings which are attended by Probation, Prison, and the Local Authority. A list of cases for discussion at these meetings is generated from the Probation case management system – NDel ius, using the “No Fixed Abode” recorded status. The Prison Leavers Meetings are chaired by the Probation Delivery Unit (PDU) Senior Probation Officer which ensures they have insight into the pre-release work required/being undertaken by their teams in a timely manner and have the links with the housing workers to facilitate assessments and discuss need, including duty to refer situations.”

Source location

Response from HMPPS and NW Probation Service
Page 2 · response
Published 28 January 2025

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 and Probation Service, not healthcare, is responsible for prisoner release and statutory housing referrals; healthcare provides treatment and collaborates.

Verbatim wording from the response

“The Prison and Probation Service are responsible for the release and any release conditions relating to prisoners and have a statutory duty to refer to the Local Authority for housing of prisoners where required. The healthcare service works collaboratively with the prison service and Offender Management Teams providing specific healthcare treatment and will attend any multidisciplinary discharge meetings put in place by the teams to enable the correct community healthcare to support release back to the community.”

Source location

Greater Manchester Mental Health
Page 2 · response
Published 28 January 2025

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.8

  1. 1

    Introduce safeguarding policy guidance requiring care and support needs to be discussed at POM-to-COM handovers.

    Stated by HM Prison & Probation Service, Probation Service, North WestStated completedThe respondent said that this action was complete when they made their response on 28 January 2025.
  2. 2

    Require contact updates and outcome recording in NDel ius within 24 hours, with compliance monitored at weekly senior probation officer performance meetings.

    Stated by HM Prison & Probation Service, Probation Service, North WestStated completedThe respondent said that this action was complete when they made their response on 28 January 2025.
  3. 3

    Amend and reissue OMiC POM-to-COM handover guidance covering meeting timing, attendees, record keeping and release planning.

    Stated by HM Prison & Probation Service, Probation Service, North WestStated completedThe respondent said that this action was complete when they made their response on 28 January 2025.
  4. 4

    Share learning from the death’s circumstances more widely with colleagues across the Probation Regions.

    Stated by HM Prison & Probation Service, Probation Service, North WestStated plannedThe respondent said that this action was planned when they made their response on 28 January 2025.
  5. 5

    Review the quality, timeliness and information-sharing arrangements of POM-to-COM handovers and develop relevant recommendations.

    Stated by HM Prison & Probation Service, Probation Service, North WestStated in progressThe respondent said that this action was in progress when they made their response on 28 January 2025.
  6. 6

    Retain the coroner’s findings on file for consideration during the next HMP Wymott inspection.

    Stated by HM Inspectorate of PrisonsStated plannedThe respondent said that this action was planned when they made their response on 28 January 2025.
  7. 7

    Implement discharge clinics two weeks before release to arrange medication, GP registration and onward community referrals.

    Stated by Greater Manchester Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 January 2025.
  8. 8

    Have healthcare staff attend monthly through-the-gate meetings to identify prisoners with complex health needs requiring post-release support.

    Stated by Greater Manchester Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 January 2025.

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 safeguarding policy guidance requiring care and support needs to be discussed at POM-to-COM handovers.

Verbatim wording from the response

“There is also a new policy statement for Practitioners in respect of safeguarding adults at risk - The Safeguarding Adults at Risk in the Community Probation Service Policy Statement and care and support needs should be discussed at the POM to COM handover meeting.”

Source location

Response from HMPPS and NW Probation Service
Page 2 · response
Published 28 January 2025

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 contact updates and outcome recording in NDel ius within 24 hours, with compliance monitored at weekly senior probation officer performance meetings.

Verbatim wording from the response

“I can also confirm that there is an expectation that the case management system NDel ius should be updated within twenty-four hours of all contacts taking place and recording of contact outcomes is currently being monitored at weekly performance meetings led by senior probation officers.”

Source location

Response from HMPPS and NW Probation Service
Page 2 · response
Published 28 January 2025

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

Amend and reissue OMiC POM-to-COM handover guidance covering meeting timing, attendees, record keeping and release planning.

Verbatim wording from the response

“The OMiC (Offender Management in Custody) POM to COM Handover Guidance was amended and re-issued in March 2024. This provides clear instructions about the requirements for the handover process from a prison-based offender manager (POM) to a community based offender manager (COM). The Guidance sets out very clear instructions on the timing of this meeting, who should attend and record keeping so that what is discussed forms the basis of planning for release.”

Source location

Response from HMPPS and NW Probation Service
Page 1 · response
Published 28 January 2025

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 learning from the death’s circumstances more widely with colleagues across the Probation Regions.

Verbatim wording from the response

“Thank you for bringing these matters of concern to my attention. Please be assured that learning from the circumstances of this tragic death will also be shared more widely with colleagues across the Probation Regions.”

Source location

Response from HMPPS and NW Probation Service
Page 2 · response
Published 28 January 2025

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 quality, timeliness and information-sharing arrangements of POM-to-COM handovers and develop relevant recommendations.

Verbatim wording from the response

“There has also been a review commissioned by the Area Executive Director to look at the quality of POM to COM handovers which proposes relevant recommendations to improve timeliness and quality in respect of the exchange and sharing of information with stakeholders both in the prison and the community.”

Source location

Response from HMPPS and NW Probation Service
Page 2 · response
Published 28 January 2025

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

Retain the coroner’s findings on file for consideration during the next HMP Wymott inspection.

Verbatim wording from the response

“We will keep your findings on file so that, when we next inspect HMP Wymott, inspectors are aware of this information and can follow up as appropriate.”

Source location

Response from HM Inspectorate of Prisons
Page 1 · response
Published 28 January 2025

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

Implement discharge clinics two weeks before release to arrange medication, GP registration and onward community referrals.

Verbatim wording from the response

“During the Inquest, evidence from the Head of Healthcare at HMP Wymott was heard, setting out that the Healthcare service has implemented discharge clinics, 2 weeks prior to prisoner release, to ensure that medication, GP registration and onwards community referrals are in place prior to release.”

Source location

Greater Manchester Mental Health
Page 2 · response
Published 28 January 2025

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

Have healthcare staff attend monthly through-the-gate meetings to identify prisoners with complex health needs requiring post-release support.

Verbatim wording from the response

“In addition, healthcare staff now attend the monthly ‘through the gate’ meetings with the Offender Management team, which will highlight any prisoners that have complex health needs and may require healthcare support post release.”

Source location

Greater Manchester Mental Health
Page 2 · response
Published 28 January 2025

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