PFD report

Miss Kirsty Walker · Prevention of Future Deaths report

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Issued 19 Dec 2018•Surrey

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.

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Concerns
1

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
12

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 raised1

  1. Delays in transferring prisoners to secure hospitals under s.47 of the Mental Health Act 1983
    Part of recurring concern: Failure to ensure safe prisoner transfersPart of recurring concern: Unreliable Mental Health Act detention arrangements
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.9

  1. Action

    Submit revised prisoner transfer and remission guidance for public consultation.

    Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 17 May 2019.
  2. Action

    Implement the revised prisoner transfer and remission guidance nationally after consultation.

    Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 17 May 2019.
  3. Action

    Develop improved performance management through increased collection and analysis of transfer pathway data.

    Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 17 May 2019.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.4

  1. Position

    NHS England is responsible for commissioning prison healthcare and secure mental health beds, so it must respond in detail.

    Stated by Department of Health and Social CareRedirects 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

Delays in transferring prisoners to secure hospitals under s.47 of the Mental Health Act 1983

Wider context from the report

“I am concerned that the average time to transfer a prisoner to a secure hospital under s.47 of the Mental Health Act 1983 is well in excess of the 14 days envisaged by the 2009 Bradley Report and presents a risk of further deaths. ”

Is this part of a recurring concern?

Yes — Failure to ensure safe prisoner transfers; Unreliable Mental Health Act detention arrangements.

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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

Submit revised prisoner transfer and remission guidance for public consultation.

Verbatim wording from the response

“NHS England has regard to the above Good Practice Guide in relation to transfer times from prison to mental health inpatient services and is now responsible for reviewing the Good Practice Guide. The aim of the review is to provide for more clinically informed timescales for the transfer and remission of prisoners to and from mental health hospital. This revised document has been developed with stakeholders and is currently being prepared in readiness for public consultation which is anticipated to take place early in 2019.”

Source location

2018-0396-Response-by-NHS-England
Page 2 · response
Published 17 May 2019

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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

Implement the revised prisoner transfer and remission guidance nationally after consultation.

Verbatim wording from the response

“As above a review of the Good Practice Guidance 2011 has taken place, led by NHS England. The revised guidance will be submitted for public consultation prior to implementation nationally, and will consider the whole process of referral, assessment, transfer and remission.”

Source location

2018-0396-Response-by-NHS-England
Page 4 · response
Published 17 May 2019

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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

Develop improved performance management through increased collection and analysis of transfer pathway data.

Verbatim wording from the response

“2. Improved performance management through increased and improved collection and analysis of data;”

Source location

2018-0396-Response-by-NHS-England
Page 3 · response
Published 17 May 2019

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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 demand and capacity reviews for adult high-, medium- and low-secure mental health services.

Verbatim wording from the response

“3. A demand and capacity review in relation to adult high, medium and low-secure services;”

Source location

2018-0396-Response-by-NHS-England
Page 3 · response
Published 17 May 2019

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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

Complete the review of guidance on prisoner transfer and remission under sections 47 and 48 of the Mental Health Act.

Verbatim wording from the response

“NHS England has regard to the above Good Practice Guide in relation to transfer times from prison to mental health inpatient services and is now responsible for reviewing the Good Practice Guide. The aim of the review is to provide for more clinically informed timescales for the transfer and remission of prisoners to and from mental health hospital. This revised document has been developed with stakeholders and is currently being prepared in readiness for public consultation which is anticipated to take place early in 2019.”

Source location

2018-0396-Response-by-NHS-England
Page 2 · response
Published 17 May 2019

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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

Roll out nationally the provider-led management of adult medium- and low-secure service budgets and whole-pathway responsibility.

Verbatim wording from the response

“4. An initiative was proposed in December 2015 and then piloted from 2016, where mental health care providers were encouraged to take on the management of tertiary budgets for adult medium and low secure services and were able to work in partnership with other providers to enable the local system to be responsive and take ownership of the whole pathway including where that related to prison transfers. In February 2018 it was agreed that this approach would be rolled out nationally;”

Source location

2018-0396-Response-by-NHS-England
Page 3 · response
Published 17 May 2019

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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

Develop a prison transfer service within a secure inpatient service to provide dedicated transfer and remission capacity.

Verbatim wording from the response

“Another example of good practice is the development of a prison transfer service within a secure inpatient service. This service focuses specifically on transfers from prison, enabling timely transfers and remission where appropriate to ensure that particular capacity is used exclusively for this patient group.”

Source location

2018-0396-Response-by-NHS-England
Page 4 · response
Published 17 May 2019

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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 annual audits benchmarking prisoner transfer and remission data, including the current audit cycle.

Verbatim wording from the response

“1. An annual audit benchmarking data in relation to the transfer and remission process;”

Source location

2018-0396-Response-by-NHS-England
Page 3 · response
Published 17 May 2019

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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

Disseminate identified good-practice examples from prison-to-mental-health transfer pathways nationally.

Verbatim wording from the response

“In respect to the improved performance management and capability that is being developed in this area, good practice examples relating to the pathway between prisons and respective mental health inpatient services are being identified in some parts of the country and processes to disseminate and share this information nationally is a specific focus.”

Source location

2018-0396-Response-by-NHS-England
Page 4 · response
Published 17 May 2019

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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

NHS England is responsible for commissioning prison healthcare and secure mental health beds, so it must respond in detail.

Verbatim wording from the response

“You issued your report to NHS England as well as the Department. NHS England is responsible for the commissioning of prison health care services and the commissioning of specialist mental health services, including secure adult mental health beds. It is therefore for NHS England to respond to you in detail. However, I am aware of, and hope you will be assured by, the work currently being undertaken by NHS England around improving access to mental health services, including secure inpatient care, for offenders with mental health difficulties.”

Source location

2018-0396-Response-by-Department-of-Health-and-Social-Care
Page 1 · response
Published 17 May 2019

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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 report does not establish the extent to which delayed transfer contributed to the death.

Verbatim wording from the response

“I have noted the concerns raised in your report about the length of time it takes to transfer a prisoner to a secure hospital under section 47 of the Mental Health Act 1983¹ and the risk this poses to future deaths. It is not clear from the detail in the report as to the extent that this was a contributing factor in the death of Miss Walker. However, I acknowledge the evidence given at inquest in relation to this and the cause for concern of future deaths.”

Source location

2018-0396-Response-by-Department-of-Health-and-Social-Care
Page 1 · response
Published 17 May 2019

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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 Mental Health Act sets no transfer deadline, and the proposed 14-day target was guidance rather than an accepted statutory requirement.

Verbatim wording from the response

“The provisions of the MHA 1983 do not stipulate a timescale within which prisoner transfers from prison to mental health inpatient services must take place.”

Source location

2018-0396-Response-by-NHS-England
Page 2 · response
Published 17 May 2019

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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

Secondary mental health providers and CCGs hold responsibility for planning or commissioning relevant local mental health pathways and beds.

Verbatim wording from the response

“Under the HSCA 2012, NHS England has responsibility for the commissioning of healthcare in prisons and the commissioning of adult secure mental health beds, amongst other specialist mental health services. More recently NHS England has devolved responsibility to secondary MH providers in respect of managing budgets and planning for their local populations. These New Care Models (NCMs) comprise of a lead provider arrangement or a collaborative of providers who are responsible for planning the pathway for their local populations in terms of adult medium and low secure services. Clinical Commissioning Groups (CCGs) are responsible for the commissioning of other mental health services, including psychiatric intensive care units (PICU).”

Source location

2018-0396-Response-by-NHS-England
Page 1 · response
Published 17 May 2019

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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.3

  1. 1

    Develop pilot sites for intensive community forensic models supporting earlier discharge from secure hospitals.

    Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 17 May 2019.
  2. 2

    Revise the high-secure mental health service specification.

    Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 17 May 2019.
  3. 3

    Maintain revised service specifications for adult medium- and low-secure services.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 17 May 2019.

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

Develop pilot sites for intensive community forensic models supporting earlier discharge from secure hospitals.

Verbatim wording from the response

“5. The development of pilot sites for intensive community forensic models of care to enable earlier discharge with appropriate levels of support outside secure hospitals;”

Source location

2018-0396-Response-by-NHS-England
Page 3 · response
Published 17 May 2019

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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

Revise the high-secure mental health service specification.

Verbatim wording from the response

“6. Revised service specifications for adult medium and low secure services, ongoing work to revise the high secure service specification.”

Source location

2018-0396-Response-by-NHS-England
Page 3 · response
Published 17 May 2019

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

Maintain revised service specifications for adult medium- and low-secure services.

Verbatim wording from the response

“6. Revised service specifications for adult medium and low secure services, ongoing work to revise the high secure service specification.”

Source location

2018-0396-Response-by-NHS-England
Page 3 · response
Published 17 May 2019

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