PFD report

Thomas Nicol · Prevention of Future Deaths report

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Issued 30 Nov 2018•Hertfordshire

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 in acute mental health crisis to suitable secure hospitals
    Part of recurring concern: Failure to ensure safe prisoner transfers
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.11

  1. Action

    Use audit findings to identify delays, develop best practice and improve escalation processes, including through a standardised information template.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 10 May 2019.
  2. Action

    Undertake a strategic demand-and-capacity review of adult high-secure services.

    Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 10 May 2019.
  3. Action

    Implement nationally the revised integrated prison mental-health service specification, including seven-day provision, quality standards and local transfer-remission navigator functions.

    Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 10 May 2019.

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

  1. Position

    NHS England is responsible for commissioning prison healthcare and specialist secure mental health beds.

    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 in acute mental health crisis to suitable secure hospitals

Wider context from the report

“That the length of time taken to transfer prisoners in acute mental health crisis to a suitable secure hospital potentially puts lives at risk ”

Is this part of a recurring concern?

Yes — Failure to ensure safe prisoner transfers.

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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

Use audit findings to identify delays, develop best practice and improve escalation processes, including through a standardised information template.

Verbatim wording from the response

“These audits permit scrutiny on a national and local level and have helped to develop a better understanding of any obstacles leading to delays in the timely assessment and if appropriate, transfer and/or remission of prisoners to and from mental health in-patient services. This knowledge is being used to build on best practice and identify areas for further service development. For example, a previous audit led to the examination of the escalation process to be applied regionally and nationally to those persons for whom an assessment and / or referral remained outstanding. The audit indicated that gaps in the information required to facilitate the escalation of care incurred a delay in its processing. As a result, a template was developed confirming”

Source location

2018-0375-Response-by-NHS-England
Page 2 · response
Published 10 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

Undertake a strategic demand-and-capacity review of adult high-secure services.

Verbatim wording from the response

“4. Demand and capacity service reviews in relation to adult high secure services;”

Source location

2018-0375-Response-by-NHS-England
Page 2 · response
Published 10 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 nationally the revised integrated prison mental-health service specification, including seven-day provision, quality standards and local transfer-remission navigator functions.

Verbatim wording from the response

“In March 2018 NHS England published a new integrated prison mental health service specification which significantly revised the previous specifications. It included provision for more flexible mental health services with seven days a week provision to ensure that those in mental health care are able to access the appropriate support even at the weekends. It also, for the first time, included the Royal College of Psychiatrists Quality Network for Prison Mental Health Services (QNMHPS) standard for mental health care in prisons. These standards were written with mental health”

Source location

2018-0375-Response-by-NHS-England
Page 3 · response
Published 10 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

Review the adult high-secure service specification through stakeholder co-design and co-production.

Verbatim wording from the response

“In relation to high secure services, a similar demand and capacity review will be undertaken as part of strategic commissioning work and the current specification is being reviewed via the established NHS England processes of co-design and co-production. This review is in its early stages and NHS England aims to publish the results of this review during 2019/20.”

Source location

2018-0375-Response-by-NHS-England
Page 3 · response
Published 10 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 Good Practice Guidance to clarify and standardise transfer and remission processes.

Verbatim wording from the response

“In addition, improved performance management and capability is being developed in this area. Good practice examples relating to the pathway in some parts of the country within prison and respective mental health in-patient services are being identified and processes to disseminate and share this information nationally is a specific focus. For example, a national transfer and remission best practice conference is scheduled to take place on 19 March 2019 which will allow NHS England to present its findings and service expectations to local commissioners and providers alike, particularly in relation to escalation processes. In addition, responsibility for reviewing the Good Practice Guidance 2011 has been passed to NHS England, which is revising this document in order to clarify and standardise the transfer process.”

Source location

2018-0375-Response-by-NHS-England
Page 3 · response
Published 10 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 and maintain national annual audits benchmarking prisoner mental-health transfers and remissions.

Verbatim wording from the response

“1. An annual audit benchmarking data in relation to transfers and remissions;”

Source location

2018-0375-Response-by-NHS-England
Page 2 · response
Published 10 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 and capability for the prisoner mental-health transfer pathway.

Verbatim wording from the response

“2. Improved performance management and capability;”

Source location

2018-0375-Response-by-NHS-England
Page 2 · response
Published 10 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 and reconfigure adult low- and medium-secure services to improve geographical access, capacity and throughput.

Verbatim wording from the response

“3. Demand and capacity service reviews in relation to adult low and medium secure services, an initiative to increase local ownership of the pathway through collaborative commissioning and the development of new forensic community models of care;”

Source location

2018-0375-Response-by-NHS-England
Page 2 · response
Published 10 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

Identify and disseminate national good-practice examples and service expectations through a scheduled transfer and remission conference.

Verbatim wording from the response

“In addition, improved performance management and capability is being developed in this area. Good practice examples relating to the pathway in some parts of the country within prison and respective mental health in-patient services are being identified and processes to disseminate and share this information nationally is a specific focus. For example, a national transfer and remission best practice conference is scheduled to take place on 19 March 2019 which will allow NHS England to present its findings and service expectations to local commissioners and providers alike, particularly in relation to escalation processes. In addition, responsibility for reviewing the Good Practice Guidance 2011 has been passed to NHS England, which is revising this document in order to clarify and standardise the transfer process.”

Source location

2018-0375-Response-by-NHS-England
Page 3 · response
Published 10 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

Submit the revised transfer and remission guidance for public consultation before national implementation.

Verbatim wording from the response

“The proposed guidance will be submitted for public consultation prior to implementation nationally.”

Source location

2018-0375-Response-by-NHS-England
Page 3 · response
Published 10 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

Pilot specialist forensic community-care models and collaborative commissioning approaches to increase local ownership of the pathway.

Verbatim wording from the response

“3. Demand and capacity service reviews in relation to adult low and medium secure services, an initiative to increase local ownership of the pathway through collaborative commissioning and the development of new forensic community models of care;”

Source location

2018-0375-Response-by-NHS-England
Page 2 · response
Published 10 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 specialist secure mental health beds.

Verbatim wording from the response

“Alongside the Department, you issued your report to the Ministry of Justice and NHS England. I am advised that NHS England has responded in detail to your concerns. As you will know, 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.”

Source location

2018-0375-Response-by-Department-of-Health-Social-Care
Page 1 · response
Published 10 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.1

  1. 1

    Implement the new adult medium- and low-secure service specifications with providers.

    Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 10 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

Implement the new adult medium- and low-secure service specifications with providers.

Verbatim wording from the response

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

Source location

2018-0375-Response-by-NHS-England
Page 2 · response
Published 10 May 2019

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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