PFD report

Stephen Philip Owen Farrar · Prevention of Future Deaths report

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Issued 29 Aug 2014•Milton Keynes

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
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
7

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 complete formal self-harm or suicide risk assessments on prison admission
    Part of recurring concern: Ineffective prison suicide and self-harm prevention systemsPart of recurring concern: Unreliable assessment of suicide and self-harm risk
  2. Unavailability of a formal self-harm or suicide risk assessment tool in prisons
    Part of recurring concern: Ineffective prison suicide and self-harm prevention systemsPart of recurring concern: Unreliable assessment of suicide and self-harm risk
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

    Train healthcare staff to use the improved risk-assessment process.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 29 August 2014.
  2. Action

    Remind reception and first-night staff to gather relevant information and consider relevant risk factors.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 29 August 2014.
  3. Action

    Improve the healthcare staff risk-assessment process.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 29 August 2014.

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

  1. Position

    Existing processes, including limited screening tools, are considered sufficient without a formal risk-assessment tool across the prison estate.

    Stated by HM Prison and Probation ServiceExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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 complete formal self-harm or suicide risk assessments on prison admission

Wider context from the report

“[BRIEF SUMMARY OF MATTERS OF CONCERN] (1)That when Mr Farrar was first admitted to Woodhill Prison there was formal risk assessment completed as to the risk of self harm or suicide despite the fact that he was under the age of 30,was returning to prison, had a history of previous self harm, and had mental health problems in the past including depression. Almost any risk assessment tool would have identified him as high risk. (2) I was told that there is no formal risk assessment tool available in any of our prisons. ”

Is this part of a recurring concern?

Yes — Ineffective prison suicide and self-harm prevention systems; Unreliable assessment of suicide and self-harm risk.

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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

Unavailability of a formal self-harm or suicide risk assessment tool in prisons

Wider context from the report

“[BRIEF SUMMARY OF MATTERS OF CONCERN] (1)That when Mr Farrar was first admitted to Woodhill Prison there was formal risk assessment completed as to the risk of self harm or suicide despite the fact that he was under the age of 30,was returning to prison, had a history of previous self harm, and had mental health problems in the past including depression. Almost any risk assessment tool would have identified him as high risk. (2) I was told that there is no formal risk assessment tool available in any of our prisons. ”

Is this part of a recurring concern?

Yes — Ineffective prison suicide and self-harm prevention systems; Unreliable assessment of suicide and self-harm risk.

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

Train healthcare staff to use the improved risk-assessment process.

Verbatim wording from the response

“Further action has also been taken locally at HMP Woodhill to address the matters about which you have expressed concern. This is described in detail in the action plan that addresses the recommendations of the Prisons and Probation Ombudsman’s (PPO’s) investigation into Mr Farrar’s death, included in the final PPO report. In brief, the staff involved in the reception and first night processes have been reminded of the need to gather all relevant information, and of the factors that they should consider when assessing risk. The risk assessment process used by healthcare staff has also been improved and staff trained in its use.”

Source location

2014-0386-Response-by-NOMS
Page 1 · response
Published 29 August 2014

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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

Remind reception and first-night staff to gather relevant information and consider relevant risk factors.

Verbatim wording from the response

“Further action has also been taken locally at HMP Woodhill to address the matters about which you have expressed concern. This is described in detail in the action plan that addresses the recommendations of the Prisons and Probation Ombudsman’s (PPO’s) investigation into Mr Farrar’s death, included in the final PPO report. In brief, the staff involved in the reception and first night processes have been reminded of the need to gather all relevant information, and of the factors that they should consider when assessing risk. The risk assessment process used by healthcare staff has also been improved and staff trained in its use.”

Source location

2014-0386-Response-by-NOMS
Page 1 · response
Published 29 August 2014

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

Improve the healthcare staff risk-assessment process.

Verbatim wording from the response

“Further action has also been taken locally at HMP Woodhill to address the matters about which you have expressed concern. This is described in detail in the action plan that addresses the recommendations of the Prisons and Probation Ombudsman’s (PPO’s) investigation into Mr Farrar’s death, included in the final PPO report. In brief, the staff involved in the reception and first night processes have been reminded of the need to gather all relevant information, and of the factors that they should consider when assessing risk. The risk assessment process used by healthcare staff has also been improved and staff trained in its use.”

Source location

2014-0386-Response-by-NOMS
Page 1 · response
Published 29 August 2014

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

Continue improving risk identification, assessment and management processes.

Verbatim wording from the response

“In response to your renewed expression of concern, I would like to assure you that reducing the number of self-inflicted deaths in prisons remains a priority for NOMS, and that we continue to work to improve our risk identification, assessment and management processes. In response to the recent rise in the number of deaths, additional dedicated resources are being provided for safer custody work in a number of prisons, and we have put in place additional staff at regional level to support staff in prisons and to share good practice. A learning and knowledge management team at headquarters provides further support to prisons in learning from deaths in custody and for safer custody work more generally.”

Source location

2014-0386-Response-by-NOMS
Page 1 · response
Published 29 August 2014

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

Existing processes, including limited screening tools, are considered sufficient without a formal risk-assessment tool across the prison estate.

Verbatim wording from the response

“I note that you raised similar concerns in a Regulation 28 Report following an inquest held in February 2014 into a death at HMP Woodhill in May 2013, and that you received a detailed response to that report from my colleague ████████ on 12 June 2014. I will not repeat the description of the policy framework given there. In summary there is a comprehensive set of systems for identifying and assessing prisoners at risk that includes some specific tools, such as a healthcare reception screening tool that has been made available to all prison establishments, but, of necessity, such tools form only a small part of the very broad set of processes involved in this complex task.”

Source location

2014-0386-Response-by-NOMS
Page 1 · response
Published 29 August 2014

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.3

  1. 1

    Provide headquarters learning and knowledge-management support for learning from custodial deaths and safer-custody work.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 29 August 2014.
  2. 2

    Provide additional dedicated resources for safer custody work in selected prisons.

    Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 29 August 2014.
  3. 3

    Provide additional regional staff to support prisons and share safer-custody good practice.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 29 August 2014.

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 headquarters learning and knowledge-management support for learning from custodial deaths and safer-custody work.

Verbatim wording from the response

“In response to your renewed expression of concern, I would like to assure you that reducing the number of self-inflicted deaths in prisons remains a priority for NOMS, and that we continue to work to improve our risk identification, assessment and management processes. In response to the recent rise in the number of deaths, additional dedicated resources are being provided for safer custody work in a number of prisons, and we have put in place additional staff at regional level to support staff in prisons and to share good practice. A learning and knowledge management team at headquarters provides further support to prisons in learning from deaths in custody and for safer custody work more generally.”

Source location

2014-0386-Response-by-NOMS
Page 1 · response
Published 29 August 2014

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 additional dedicated resources for safer custody work in selected prisons.

Verbatim wording from the response

“In response to your renewed expression of concern, I would like to assure you that reducing the number of self-inflicted deaths in prisons remains a priority for NOMS, and that we continue to work to improve our risk identification, assessment and management processes. In response to the recent rise in the number of deaths, additional dedicated resources are being provided for safer custody work in a number of prisons, and we have put in place additional staff at regional level to support staff in prisons and to share good practice. A learning and knowledge management team at headquarters provides further support to prisons in learning from deaths in custody and for safer custody work more generally.”

Source location

2014-0386-Response-by-NOMS
Page 1 · response
Published 29 August 2014

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 additional regional staff to support prisons and share safer-custody good practice.

Verbatim wording from the response

“In response to your renewed expression of concern, I would like to assure you that reducing the number of self-inflicted deaths in prisons remains a priority for NOMS, and that we continue to work to improve our risk identification, assessment and management processes. In response to the recent rise in the number of deaths, additional dedicated resources are being provided for safer custody work in a number of prisons, and we have put in place additional staff at regional level to support staff in prisons and to share good practice. A learning and knowledge management team at headquarters provides further support to prisons in learning from deaths in custody and for safer custody work more generally.”

Source location

2014-0386-Response-by-NOMS
Page 1 · response
Published 29 August 2014

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