PFD report

Richard Scott Green · Prevention of Future Deaths report

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Issued 2 Nov 2015•Cumbria

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
3

Raised in this report

Recipients
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
3

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 raised3

  1. Failure of clinicians to review patients’ historical medical records
    Part of recurring concern: Failure to review relevant clinical records before care decisions
  2. Failure of SystmOne to provide usable search and clear flagging of important historical information
    Part of recurring concern: Electronic patient records failing to make relevant clinical information available and actionablePart of recurring concern: Failure to keep historical risk information accessible for later risk assessmentPart of recurring concern: Unreliable operation of SystmOne for safety-critical prisoner information
  3. Lack of a reliable tool for assessing depression in 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

    Re-procure the electronic healthcare system with improved sharing of risk indicators between healthcare services and NOMS.

    Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 2 November 2015.
  2. Action

    Provide full training and regular training updates for the new electronic healthcare system.

    Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 2 November 2015.
  3. Action

    Implement an interface between healthcare services and NOMS to share risk indicators and support proactive risk management.

    Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 2 November 2015.

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 of clinicians to review patients’ historical medical records

Wider context from the report

“I was clear that serious incidents of self-harm/suicide attempts from 2007 and 2013 were recorded on his SystmOne records. These do not appear to have been recognised or acted upon by various medical professionals in the prison system. This meant that a nurse at screening had not read the records, neither had a GP or a mental health nurse who later carried out an assessment. The result was that throughout his prison term at Haverigg no one was aware of the history and the risk he presented. As a result, there were missed opportunities which might have made a difference. Evidence showed that a) there appeared to be no reliable tool to help assess depression in a prisoner (community tools being unsatisfactory). b) Although entries were there to be seen on System One, none of the clinicians saw them. Pressure of work and the time needed to check were reasons cited, together with lack of resources. It seems SystmOne was not easy to use, some staff being unaware they could “search” and an absence of a way to clearly flag important historical information to ensure it was at the clinicians’ finger tips. ”

Is this part of a recurring concern?

Yes — Failure to review relevant clinical records before care decisions.

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 of SystmOne to provide usable search and clear flagging of important historical information

Wider context from the report

“I was clear that serious incidents of self-harm/suicide attempts from 2007 and 2013 were recorded on his SystmOne records. These do not appear to have been recognised or acted upon by various medical professionals in the prison system. This meant that a nurse at screening had not read the records, neither had a GP or a mental health nurse who later carried out an assessment. The result was that throughout his prison term at Haverigg no one was aware of the history and the risk he presented. As a result, there were missed opportunities which might have made a difference. Evidence showed that a) there appeared to be no reliable tool to help assess depression in a prisoner (community tools being unsatisfactory). b) Although entries were there to be seen on System One, none of the clinicians saw them. Pressure of work and the time needed to check were reasons cited, together with lack of resources. It seems SystmOne was not easy to use, some staff being unaware they could “search” and an absence of a way to clearly flag important historical information to ensure it was at the clinicians’ finger tips. ”

Is this part of a recurring concern?

Yes — Electronic patient records failing to make relevant clinical information available and actionable; Failure to keep historical risk information accessible for later risk assessment; Unreliable operation of SystmOne for safety-critical prisoner information.

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

Lack of a reliable tool for assessing depression in prisoners

Wider context from the report

“I was clear that serious incidents of self-harm/suicide attempts from 2007 and 2013 were recorded on his SystmOne records. These do not appear to have been recognised or acted upon by various medical professionals in the prison system. This meant that a nurse at screening had not read the records, neither had a GP or a mental health nurse who later carried out an assessment. The result was that throughout his prison term at Haverigg no one was aware of the history and the risk he presented. As a result, there were missed opportunities which might have made a difference. Evidence showed that a) there appeared to be no reliable tool to help assess depression in a prisoner (community tools being unsatisfactory). b) Although entries were there to be seen on System One, none of the clinicians saw them. Pressure of work and the time needed to check were reasons cited, together with lack of resources. It seems SystmOne was not easy to use, some staff being unaware they could “search” and an absence of a way to clearly flag important historical information to ensure it was at the clinicians’ finger tips. ”

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

Re-procure the electronic healthcare system with improved sharing of risk indicators between healthcare services and NOMS.

Verbatim wording from the response

“In relation the second recommendation NHS England are re-procuring the healthcare electronic healthcare system, SystmOne. This system will include improvements on the current system such as the sharing of risk indicators (e.g. ‘increased risk of suicide’) between healthcare & NOMS and there is a joint commitment between NHS England and NOMS to implement the interface to show that proactive steps are being taken to address this issue in the longer term. The implementation of the new system will include a full training programme along with regular training updates undertaken.”

Source location

2015-0456 - Response from NHS England
Page 2 · response
Published 2 November 2015

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 full training and regular training updates for the new electronic healthcare system.

Verbatim wording from the response

“In relation the second recommendation NHS England are re-procuring the healthcare electronic healthcare system, SystmOne. This system will include improvements on the current system such as the sharing of risk indicators (e.g. ‘increased risk of suicide’) between healthcare & NOMS and there is a joint commitment between NHS England and NOMS to implement the interface to show that proactive steps are being taken to address this issue in the longer term. The implementation of the new system will include a full training programme along with regular training updates undertaken.”

Source location

2015-0456 - Response from NHS England
Page 2 · response
Published 2 November 2015

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 an interface between healthcare services and NOMS to share risk indicators and support proactive risk management.

Verbatim wording from the response

“In relation the second recommendation NHS England are re-procuring the healthcare electronic healthcare system, SystmOne. This system will include improvements on the current system such as the sharing of risk indicators (e.g. ‘increased risk of suicide’) between healthcare & NOMS and there is a joint commitment between NHS England and NOMS to implement the interface to show that proactive steps are being taken to address this issue in the longer term. The implementation of the new system will include a full training programme along with regular training updates undertaken.”

Source location

2015-0456 - Response from NHS England
Page 2 · response
Published 2 November 2015

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