PFD report

Sidonio Eugenio TEIXEIRA · Prevention of Future Deaths report

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Issued 12 Dec 2017•Worcestershire

Summary Report text Evidence

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: 6
Recipients: 1
Responses found: 0
Stated actions: 0

Recipients and published responses

Long Lartin PrisonNo response found

Source document

Full report text

This is the full text from the original published report.

Open published report

Explains the investigation, the inquest, the evidence considered and the coroner’s conclusion.

Describes the events and care leading up to the death.

Sets out risks the coroner believes could cause future deaths unless action is taken.

Investigation and inquest

On 20th June 2016 I commenced an investigation into the death of Sidonio Eugenio TEIXEIRA then aged 59.
The investigation concluded at the end of the inquest on 7th December 2017.

The conclusion of the inquest was narrative (attached), the medical cause of death being multiple injuries.

Circumstances of the death

Mr Teixeira was murdered in the prison by another prisoner.

Coroner’s concerns

(1) : issues arose in the course of the inquest regarding the adequacy of intelligence, the efficacy of reporting, the appropriateness of analysis, the training of analysts and the need for ongoing audit.
These issues and the adequacy of them were reflected in the narrative conclusion reached by the jury.
In the course of the inquest a witness produced a previously unseen internal (and critical) report regarding these issues which none of the witnesses had seen previously (including the head of safer custody) notwithstanding that the report had been produced over 12 months previously raising concerns that lessons might not have been shared with appropriate staff.

(2)
(3)

Concerns and recipient responses

Select any concern, action or position to view the source wording.

Report evidence summary

Concerns raised6

Lack of ongoing audit
Ineffective reporting
Inadequacy of intelligence

Inappropriateness of analysis
Failure to share lessons with appropriate staff
Inadequate training of analysts

Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

No linked response statements

No respondent-stated action or position is clearly linked to these concerns.

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 ongoing audit

Wider context from the report

“(1) : issues arose in the course of the inquest regarding the adequacy of intelligence, the efficacy of reporting, the appropriateness of analysis, the training of analysts and the need for ongoing audit. These issues and the adequacy of them were reflected in the narrative conclusion reached by the jury. In the course of the inquest a witness produced a previously unseen internal (and critical) report regarding these issues which none of the witnesses had seen previously (including the head of safer custody) notwithstanding that the report had been produced over 12 months previously raising concerns that lessons might not have been shared with appropriate staff. (2) (3) ”

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

Ineffective reporting

Wider context from the report

“(1) : issues arose in the course of the inquest regarding the adequacy of intelligence, the efficacy of reporting, the appropriateness of analysis, the training of analysts and the need for ongoing audit. These issues and the adequacy of them were reflected in the narrative conclusion reached by the jury. In the course of the inquest a witness produced a previously unseen internal (and critical) report regarding these issues which none of the witnesses had seen previously (including the head of safer custody) notwithstanding that the report had been produced over 12 months previously raising concerns that lessons might not have been shared with appropriate staff. (2) (3) ”

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

Inadequacy of intelligence

Wider context from the report

“(1) : issues arose in the course of the inquest regarding the adequacy of intelligence, the efficacy of reporting, the appropriateness of analysis, the training of analysts and the need for ongoing audit. These issues and the adequacy of them were reflected in the narrative conclusion reached by the jury. In the course of the inquest a witness produced a previously unseen internal (and critical) report regarding these issues which none of the witnesses had seen previously (including the head of safer custody) notwithstanding that the report had been produced over 12 months previously raising concerns that lessons might not have been shared with appropriate staff. (2) (3) ”

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

Inappropriateness of analysis

Wider context from the report

“(1) : issues arose in the course of the inquest regarding the adequacy of intelligence, the efficacy of reporting, the appropriateness of analysis, the training of analysts and the need for ongoing audit. These issues and the adequacy of them were reflected in the narrative conclusion reached by the jury. In the course of the inquest a witness produced a previously unseen internal (and critical) report regarding these issues which none of the witnesses had seen previously (including the head of safer custody) notwithstanding that the report had been produced over 12 months previously raising concerns that lessons might not have been shared with appropriate staff. (2) (3) ”

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 share lessons with appropriate staff

Wider context from the report

“(1) : issues arose in the course of the inquest regarding the adequacy of intelligence, the efficacy of reporting, the appropriateness of analysis, the training of analysts and the need for ongoing audit. These issues and the adequacy of them were reflected in the narrative conclusion reached by the jury. In the course of the inquest a witness produced a previously unseen internal (and critical) report regarding these issues which none of the witnesses had seen previously (including the head of safer custody) notwithstanding that the report had been produced over 12 months previously raising concerns that lessons might not have been shared with appropriate staff. (2) (3) ”

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

Inadequate training of analysts

Wider context from the report

“(1) : issues arose in the course of the inquest regarding the adequacy of intelligence, the efficacy of reporting, the appropriateness of analysis, the training of analysts and the need for ongoing audit. These issues and the adequacy of them were reflected in the narrative conclusion reached by the jury. In the course of the inquest a witness produced a previously unseen internal (and critical) report regarding these issues which none of the witnesses had seen previously (including the head of safer custody) notwithstanding that the report had been produced over 12 months previously raising concerns that lessons might not have been shared with appropriate staff. (2) (3) ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Official responses located: 0/1

Data last updated 7 September 2026

No official response is included in the current published snapshot.