PFD report

Mr Darren Clifford Docherty · Prevention of Future Deaths report

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Issued 14 Apr 2023•Staffordshire and Stoke on Trent

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
2

Named on the report

Responses found
1

Of 2 recipients

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. Failure to ensure access to GP and community mental health services for people released from prison
    Part of recurring concern: Failure to maintain healthcare continuity for prisoners after releasePart of recurring concern: Unreliable Community Mental Health care access and discharge processes
  2. Lack of accommodation for people released from prison
    Part of recurring concern: Failure to secure suitable accommodation for people released from prison
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.4

  1. Action

    Work with prison-service partners to maintain a clear referral pathway explaining housing options before release, beyond the Duty to Refer mechanism.

    Stated by Stoke-on-Trent City CouncilStated in progressThe respondent said that this action was in progress when they made their response on 29 April 2024.
  2. Action

    Work with prisons through established mechanisms, including pre-release panels, to maintain robust procedures for people released at risk of homelessness.

    Stated by Stoke-on-Trent City CouncilStated in progressThe respondent said that this action was in progress when they made their response on 29 April 2024.
  3. Action

    Work with health and social-care colleagues to link people released without accommodation to homeless healthcare, mental-health nursing and wider homelessness support services.

    Stated by Stoke-on-Trent City CouncilStated in progressThe respondent said that this action was in progress when they made their response on 29 April 2024.

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

  1. Position

    The Council cannot offer immediate accommodation to everyone leaving custody because legal duties, accommodation shortages and resource constraints limit provision.

    Stated by Stoke-on-Trent City CouncilUnable to actThe respondent said that a constraint prevented them from taking the relevant 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 ensure access to GP and community mental health services for people released from prison

Wider context from the report

“1. That when people are released from prison they do so, on many occasions, with no accommodation. Those that need GP access and community mental health services are unable to access them in these circumstances. ”

Is this part of a recurring concern?

Yes — Failure to maintain healthcare continuity for prisoners after release; Unreliable Community Mental Health care access and discharge processes.

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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 accommodation for people released from prison

Wider context from the report

“1. That when people are released from prison they do so, on many occasions, with no accommodation. Those that need GP access and community mental health services are unable to access them in these circumstances. ”

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 respondent action was interpreted

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

PFD Monitor interpretation

Work with prison-service partners to maintain a clear referral pathway explaining housing options before release, beyond the Duty to Refer mechanism.

Verbatim wording from the response

“3. We will continue to work with partners across the prison service to ensure a clear referral pathway is in place above and beyond the Duty to Refer mechanism so that everyone has a better understanding of the housing options available before a prisoner is released, however, it must be recognised that this is unlikely to result in a firm offer of accommodation for everyone especially those that have no priority need;”

Source location

Response from Stoke on Trent City Council
Page 6 · response
Published 29 April 2024

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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

Work with prisons through established mechanisms, including pre-release panels, to maintain robust procedures for people released at risk of homelessness.

Verbatim wording from the response

“2. We will continue to work with prisons to ensure robust procedures are in place for those being released at risk of homelessness through already established mechanisms such as the pre-release panel, a joint meeting between prison based accommodation staff and the Council’s dedicated Housing Needs”

Source location

Response from Stoke on Trent City Council
Page 5 · response
Published 29 April 2024

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

Work with health and social-care colleagues to link people released without accommodation to homeless healthcare, mental-health nursing and wider homelessness support services.

Verbatim wording from the response

“4. We will continue to work with colleagues in health and social care to support individuals released from prison with no accommodation to access GP and community mental health services by ensuring they are aware of and linked into the existing Homeless Healthcare Service and Rough Sleeping Mental Health nurse and the wider support available through Hanley Connects, the City Council’s Homelessness Hub and the Rough Sleeper Outreach Service.”

Source location

Response from Stoke on Trent City Council
Page 6 · response
Published 29 April 2024

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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

Review the Duty to Refer process to ensure referrals receive a response within three days.

Verbatim wording from the response

“1. We have already completed a review of the Duty to Refer process to ensure all referrals receive a response within 3 days of receipt so that prisoners due for release and their representatives in the prison service are aware they need to either approach the Housing Solutions Service within office hours or the Emergency Duty Team outside of office hours if they are released with no accommodation secured on the day of their release;”

Source location

Response from Stoke on Trent City Council
Page 5 · response
Published 29 April 2024

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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 Council cannot offer immediate accommodation to everyone leaving custody because legal duties, accommodation shortages and resource constraints limit provision.

Verbatim wording from the response

“Despite the `Duty to Refer,` there is no absolute duty on a local housing authority to provide accommodation for all households or individuals who present as homeless. It should be acknowledged and noted that most local authorities, including Stoke-on-Trent, will provide accommodation for certain non-priority households at their”

Source location

Response from Stoke on Trent City Council
Page 2 · response
Published 29 April 2024

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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

Central Government should be separately asked to consider legal duties for interim accommodation and funding for local authorities.

Verbatim wording from the response

“We as a Local Authority take our responsibilities to those leaving custody extremely seriously but regrettably do not have sufficient accommodation or resources available to make an offer of immediate accommodation at the point of presentation to everyone regardless of priority need. It is therefore suggested that the Coroner may wish to separately consider making a Report to Central Government in terms of the legal duties that apply to offers of interim accommodation, especially for those leaving custody and the allocation of funding to Local Authorities to provide this.”

Source location

Response from Stoke on Trent City Council
Page 6 · response
Published 29 April 2024

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 Council cannot directly address access to GP or community mental health services because it does not commission those services.

Verbatim wording from the response

“Whilst the local authority does not commission GP or community mental health services and is therefore not in a position to directly address these concerns, it is aware that homelessness should not be a barrier to registration with a GP.”

Source location

Response from Stoke on Trent City Council
Page 3 · response
Published 29 April 2024

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