PFD report

Jamie Lee Bennett · Prevention of Future Deaths report

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Issued 29 Apr 2022•South Yorkshire (Western)

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
4

Raised in this report

Recipients
3

Named on the report

Responses found
1

Of 3 recipients

Stated actions
5

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 raised4

  1. Lack of written instructions for conducting welfare checks
    Part of recurring concern: Unreliable welfare-check processes for people whose health is of concern
  2. Unclear allocation of task-list responsibilities during night-shift agency cover
    Part of recurring concern: Unreliable allocation and completion of night-shift care tasks
  3. Gaps in communication of crucial substance-misuse and Naloxone information to Approved Premises
    Part of recurring concern: Unreliable information sharing for prison-to-community discharge coordinationPart of recurring concern: Unreliable inter-agency information sharing for coordinated care
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

    Implement a tracked, consent-based process for quality-assured Approved Premises information reports, recording requests and completed reports on SystmOne.

    Stated by Practice Plus GroupStated completedThe respondent said that this action was complete when they made their response on 12 May 2022.
  2. Action

    Update the Naloxone refusal disclaimer and require refusals to be signed, scanned onto SystmOne and recorded in third-party medical reports.

    Stated by Practice Plus GroupStated completedThe respondent said that this action was complete when they made their response on 12 May 2022.
  3. Action

    Draft a detailed patient-release information template covering substance misuse, Naloxone, mental health and other relevant support needs.

    Stated by Practice Plus GroupStated completedThe respondent said that this action was complete when they made their response on 12 May 2022.

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 written instructions for conducting welfare checks

Wider context from the report

“The evidence was unclear as to who will carry out actions on the task lists on a night shift when a Sodexo worker was replaced by agency staff. There is no audit process in place to ensure staff are carrying out tasks in accordance with the lists issued There are no written instructions on how to conduct welfare checks. There is no audit process in place to ensure staff are conducting welfare checks appropriately It is my opinion there is a risk that future deaths may occur unless there are: • Clear, written instructions on how to conduct welfare checks • Clarity around which member of staff will be responsible for which task list, particularly on a night shift when a Sodexo worker is replaced by agency staff • An audit process put in place to ensure staff are carrying out tasks in accordance with the lists issued and in particular are conducting welfare checks appropriately ”

Is this part of a recurring concern?

Yes — Unreliable welfare-check processes for people whose health is of concern.

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

Unclear allocation of task-list responsibilities during night-shift agency cover

Wider context from the report

“The evidence was unclear as to who will carry out actions on the task lists on a night shift when a Sodexo worker was replaced by agency staff. There is no audit process in place to ensure staff are carrying out tasks in accordance with the lists issued There are no written instructions on how to conduct welfare checks. There is no audit process in place to ensure staff are conducting welfare checks appropriately It is my opinion there is a risk that future deaths may occur unless there are: • Clear, written instructions on how to conduct welfare checks • Clarity around which member of staff will be responsible for which task list, particularly on a night shift when a Sodexo worker is replaced by agency staff • An audit process put in place to ensure staff are carrying out tasks in accordance with the lists issued and in particular are conducting welfare checks appropriately ”

Is this part of a recurring concern?

Yes — Unreliable allocation and completion of night-shift care tasks.

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

Gaps in communication of crucial substance-misuse and Naloxone information to Approved Premises

Wider context from the report

“There were gaps in the information provided by HMP Moorlands to Norfolk Park Bail Hostel, in particular his history of substance misuse and that Jamie had refused Naloxone. The Court heard evidence that information sharing with third parties is in line with national guidelines, but also that there should have been another report by the offender management services that would have been more detailed and would have given this information to Norfolk Park. I do feel that if Norfolk Park Bail Hostel had that information, they would have been in a better position to support Jamie during those first crucial 48 hours and that may have reduced the risk of him using substances and dying It is my view there should be a process by which crucial information about a patient is communicated to the Approved Premise, specifically substance misuse history, any substance misuse work, any detox or re-toxification processes undertaken, and whether the patient has accepted or refused Naloxone and any community drugs services referral. It is my view this will assist the Approved Premise to determine the level of support to be offered to a resident, especially those that are released on a Friday and will have limited support from anywhere other than an Approved Premise during the first 48 hours It is my opinion there is a risk that future deaths may occur unless such a process is developed ”

Is this part of a recurring concern?

Yes — Unreliable information sharing for prison-to-community discharge coordination; Unreliable inter-agency information sharing for coordinated care.

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 auditing of task-list completion and welfare-check performance

Wider context from the report

“The evidence was unclear as to who will carry out actions on the task lists on a night shift when a Sodexo worker was replaced by agency staff. There is no audit process in place to ensure staff are carrying out tasks in accordance with the lists issued There are no written instructions on how to conduct welfare checks. There is no audit process in place to ensure staff are conducting welfare checks appropriately It is my opinion there is a risk that future deaths may occur unless there are: • Clear, written instructions on how to conduct welfare checks • Clarity around which member of staff will be responsible for which task list, particularly on a night shift when a Sodexo worker is replaced by agency staff • An audit process put in place to ensure staff are carrying out tasks in accordance with the lists issued and in particular are conducting welfare checks appropriately ”

Is this part of a recurring concern?

Yes — Failure of care and safety auditing to identify deficiencies.

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

Implement a tracked, consent-based process for quality-assured Approved Premises information reports, recording requests and completed reports on SystmOne.

Verbatim wording from the response

“• A process has been immediately implemented for managing all Approved Premises information requests: – Requests for patient information received are logged onto a spreadsheet for tracking the process. – All information/medical report requests received are scanned onto the patient record on SystmOne. – Consent to share information is signed by the patient and scanned onto the patient record (SystmOne). – The Medical Record template is completed by a manager, quality assured and shared with the requesting provider. – The completed report is scanned onto the patient record (SystmOne) providing an audit trail.”

Source location

Response from Practice Plus Group
Page 2 · response
Published 12 May 2022

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

Update the Naloxone refusal disclaimer and require refusals to be signed, scanned onto SystmOne and recorded in third-party medical reports.

Verbatim wording from the response

“• Patients are provided with advice on discharge, where appropriate, about Naloxone. I understand this occurred in the case of Jamie Lee Bennett. However, in order for greater clarity and clinical safety, the disclaimer form for Naloxone has now been updated to make the risks of not accepting Naloxone clearer, please see Appendix B. When a”

Source location

Response from Practice Plus Group
Page 2 · response
Published 12 May 2022

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

Draft a detailed patient-release information template covering substance misuse, Naloxone, mental health and other relevant support needs.

Verbatim wording from the response

“Following the Inquest, PPG Healthcare reflected on the type of information being requested and determined that more information should be shared. Therefore, Healthcare have drafted a more detailed template (attached for reference), which provides more specific information including, medical conditions, medication, COVID vaccinations, social services input, mental health concerns including history of self-harm, and specific equipment the patient may require, substance misuse involvement including SMS history, any current substance misuse work, any detox or re-toxification processes undertaken, whether the patient has been offered and trained for Naloxone and details of any community drugs service referrals that may have been made.”

Source location

Response from Practice Plus Group
Page 2 · response
Published 12 May 2022

Open published response

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.2

  1. 1

    Share lessons learned from the inquest across Practice Plus Group services.

    Stated by Practice Plus GroupStated plannedThe respondent said that this action was planned when they made their response on 12 May 2022.
  2. 2

    Hold a reflective practice session with the Healthcare team to review Naloxone processes.

    Stated by Practice Plus GroupStated completedThe respondent said that this action was complete when they made their response on 12 May 2022.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    Approved Premises and Probation Service are responsible for the information requests and templates, not Practice Plus Group.

    Stated by Practice Plus GroupRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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

Share lessons learned from the inquest across Practice Plus Group services.

Verbatim wording from the response

“Practice Plus Group is committed to ensuring the high quality provision of healthcare services to all prisoners at HMP Moorlands and that this extends through the gate when being released. We will also ensure that the lessons learnt as a result of this inquest are shared across all of Practice Plus Group’s services.”

Source location

Response from Practice Plus Group
Page 3 · response
Published 12 May 2022

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

Hold a reflective practice session with the Healthcare team to review Naloxone processes.

Verbatim wording from the response

“• A reflective practice session has been held with the Healthcare team following the inquest to review our processes around Naloxone.”

Source location

Response from Practice Plus Group
Page 2 · response
Published 12 May 2022

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

Approved Premises and Probation Service are responsible for the information requests and templates, not Practice Plus Group.

Verbatim wording from the response

“It should be noted that the template provided in the case of Jamie Lee Bennett was not created by PPG; we are not responsible for the requests and templates provided by the Approved Premises/Probation service.”

Source location

Response from Practice Plus Group
Page 2 · response
Published 12 May 2022

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