Aaron Taylor
PFD Report
Partially Responded
Ref: 2025-0565
82 days overdue · 2 responses outstanding
Sent To
Response Status
Responses
1 of 3
56-Day Deadline
1 Jan 2026
82 days past deadline — 2 responses outstanding
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner’s Concerns
Evidence was heard that PPG Healthcare who are now responsible for healthcare at HMP Garth have not had any psychologist resource for prisoners at HMP Garth unless they have been victims of sexual assault. Even then, evidence was heard about waiting lists of many months. Evidence was also heard that a decision had not been taken to fill psychologist resource gaps by locum cover, despite those gaps having existed for 6 months
Responses
Practice Plus Group has advertised new psychologist roles at HMP Garth, contacted agencies for interim cover, and has interviews scheduled for the Principal Psychologist post. While awaiting permanent appointments, patients are supported by Health and Wellbeing Practitioners, and urgent cases receive regional psychological support.
AI summary
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Dear Sir
Regulation 28: Prevention of Future Deaths report, Aaron Taylor
Thank you for your Regulation 28 Prevention of Future Deaths Report issued to Practice Plus Group following the inquest into the death of Aaron Taylor, Deceased. Practice Plus Group would like to express its condolences to Mr Taylor’s family and friends. Practice Plus Group has been the main provider of healthcare services at HMP Garth since 1 April
2025.
This response addresses the matters of concern in so far as they relate to Practice Plus Group.
Matter of Concern: Evidence was heard that PPG Healthcare who are now responsible for healthcare at HMP Garth have not had any psychologist resource for prisoners at HMP Garth unless they have been victims of sexual assault. Even then, evidence was heard about waiting lists of many months. Evidence was also heard that a decision had not been taken to fill psychologist resource gaps by locum cover, despite those gaps having existed for 6 months
Response: The current model of psychology provision at HMP Garth consists of a 1 part-time Principal Psychologist, 1 full-time Clinical Assistant Psychologist and 2 full time Assistant Psychologists. All of these posts are new roles following TUPE of services and all posts are out to advert.
The Consultant Clinical Psychologist has contacted agencies to backfill the Principal Psychologist role in the interim. Unfortunately, no suitable locum psychologist has been available to be provided by the agency, due to a lack of psychologists in the employment market.
We currently have two candidates that have applied for the Principal Psychologist post and the Consultant Clinical Psychologist arranged telephone calls with both candidates on the 30th December 2025. Following this, the candidates have been offered interviews, which are due to take place on 21 January 2026.
No applicants have applied for the Clinical Assistant Psychologist post as yet. We have made the decision to keep the vacancy open for another month, in the hope we will receive some
HM Senior Coroner Christopher Long Lancashire and Blackburn with Darwen
By email Practice Plus Group Building 1330 Arlington Business Park Theale Reading RG7 4SA
1009801953.1 applications. In the event no candidates have applied for this post, a meeting will be held to discuss consideration of a restructure of this role. We have informed NHSE Commissioners of the possible restructure.
The Assistant Psychologist post is also out to advert. In the event candidates are appointed for this post before we have a Principal Psychologist in post, clinical supervision will be provided by a psychologist from another site within PPG.
Patients requiring routine psychology interventions who are not case loaded to a mental health nurse are provided with support from a Health and Wellbeing Practitioner and Nurse Associate, this provides ongoing support and safety-netting to patients, including monitoring and escalation to the Mental Health nursing team if required. Upon escalation they can then be case-managed by a Mental Health nurse. No further patients are being added to the waiting list while we await appointment of the psychologists. Anyone who is now referred for psychological services is allocated a health and well-being practitioner, who can undertake a lot of low level work that can be done in meantime, in preparation for psychological input.
Patients requiring urgent psychological interventions are discussed at a multi professional complex case conference (MPCCC) at a local level and referred to the Regional MPCCC for review and care planning. Provision is in place to ensure urgent patients are provided with psychological support from the region’s established psychology workforce.
HMP Garth is also having discussions with the neighbouring prison, HMP Wymott, as to whether we could share their psychological resources while we await the posts being filled.
We are committed to providing a high-quality healthcare service at HMP Garth and are doing everything we can to ensure those detained there are as safe as possible and receive the best quality care. We are deeply sorry that Aaron Taylor died while receiving care from our service and we will ensure that the lessons learnt are not just implemented at HMP Garth but across Practice Plus Group’s services.
We trust that the above responses provide the information that you require but please do not hesitate to contact us if Practice Plus Group can be of any further assistance.
Regulation 28: Prevention of Future Deaths report, Aaron Taylor
Thank you for your Regulation 28 Prevention of Future Deaths Report issued to Practice Plus Group following the inquest into the death of Aaron Taylor, Deceased. Practice Plus Group would like to express its condolences to Mr Taylor’s family and friends. Practice Plus Group has been the main provider of healthcare services at HMP Garth since 1 April
2025.
This response addresses the matters of concern in so far as they relate to Practice Plus Group.
Matter of Concern: Evidence was heard that PPG Healthcare who are now responsible for healthcare at HMP Garth have not had any psychologist resource for prisoners at HMP Garth unless they have been victims of sexual assault. Even then, evidence was heard about waiting lists of many months. Evidence was also heard that a decision had not been taken to fill psychologist resource gaps by locum cover, despite those gaps having existed for 6 months
Response: The current model of psychology provision at HMP Garth consists of a 1 part-time Principal Psychologist, 1 full-time Clinical Assistant Psychologist and 2 full time Assistant Psychologists. All of these posts are new roles following TUPE of services and all posts are out to advert.
The Consultant Clinical Psychologist has contacted agencies to backfill the Principal Psychologist role in the interim. Unfortunately, no suitable locum psychologist has been available to be provided by the agency, due to a lack of psychologists in the employment market.
We currently have two candidates that have applied for the Principal Psychologist post and the Consultant Clinical Psychologist arranged telephone calls with both candidates on the 30th December 2025. Following this, the candidates have been offered interviews, which are due to take place on 21 January 2026.
No applicants have applied for the Clinical Assistant Psychologist post as yet. We have made the decision to keep the vacancy open for another month, in the hope we will receive some
HM Senior Coroner Christopher Long Lancashire and Blackburn with Darwen
By email Practice Plus Group Building 1330 Arlington Business Park Theale Reading RG7 4SA
1009801953.1 applications. In the event no candidates have applied for this post, a meeting will be held to discuss consideration of a restructure of this role. We have informed NHSE Commissioners of the possible restructure.
The Assistant Psychologist post is also out to advert. In the event candidates are appointed for this post before we have a Principal Psychologist in post, clinical supervision will be provided by a psychologist from another site within PPG.
Patients requiring routine psychology interventions who are not case loaded to a mental health nurse are provided with support from a Health and Wellbeing Practitioner and Nurse Associate, this provides ongoing support and safety-netting to patients, including monitoring and escalation to the Mental Health nursing team if required. Upon escalation they can then be case-managed by a Mental Health nurse. No further patients are being added to the waiting list while we await appointment of the psychologists. Anyone who is now referred for psychological services is allocated a health and well-being practitioner, who can undertake a lot of low level work that can be done in meantime, in preparation for psychological input.
Patients requiring urgent psychological interventions are discussed at a multi professional complex case conference (MPCCC) at a local level and referred to the Regional MPCCC for review and care planning. Provision is in place to ensure urgent patients are provided with psychological support from the region’s established psychology workforce.
HMP Garth is also having discussions with the neighbouring prison, HMP Wymott, as to whether we could share their psychological resources while we await the posts being filled.
We are committed to providing a high-quality healthcare service at HMP Garth and are doing everything we can to ensure those detained there are as safe as possible and receive the best quality care. We are deeply sorry that Aaron Taylor died while receiving care from our service and we will ensure that the lessons learnt are not just implemented at HMP Garth but across Practice Plus Group’s services.
We trust that the above responses provide the information that you require but please do not hesitate to contact us if Practice Plus Group can be of any further assistance.
Report Sections
Investigation and Inquest
On 7 September 2023 I commenced an investigation into the death of Aaron Lee Taylor, 32 years old. The investigation concluded at the end of the inquest on 29 October 2025. The conclusion of the inquest was:
With the evidence provided by the pathologist, CCTV footage from 27 August and the 28 August, combined with witness statements from the prison officer who found Mr Aaron Lee Taylor at 08:05am on the 28 August 2023, Mr Aaron Lee Taylor died between 7.30pm on the 27 August 2023 and 6am on the 28 August 2023, in a cell on the premises of HMP Garth, 1 Moss Lane, Ulnes Walton, Leyland. .
Taking into account the three letters that Mr Taylor wrote, the preplanning and method in which Mr Taylor died, leads us to conclude Mr Taylor did take steps intending to take his own life.
There were multiple failures in the measures taken to prevent self-harm and suicide. From the evidence that has been presented in court, multiple opportunities were missed by multiple professionals (nurse, GP, prison officers, mental health nurse, Prison Offender Manager, Governor, Senior prison officer) to support or offer suitable/appropriate care and resources for Mr Taylor. Inadequate preventative steps and assessments, lack of documentation, inability to adhere to policies and procedures and a 'lack of professional curiosity' as stated by an Operations Manager from GMMH who undertook an external investigation. All contributed to Mr Taylor's death.
Witness testimony from a prison officer demonstrated that the relevant observations had not been carried out on the 28 August 2023. With the evidence and testimony of the pathologist, and the uncertainty surrounding time of death, we cannot say that these observations or lack of, contributed to Mr Taylor's death.
As highlighted by the external investigation carried out by GMMH, there were multiple serious failures to provide minimal/adequate mental health interventions for Mr Taylor. These serious failures and inadequacies possibly contributed to Mr Taylor's death..
With the evidence provided by the pathologist, CCTV footage from 27 August and the 28 August, combined with witness statements from the prison officer who found Mr Aaron Lee Taylor at 08:05am on the 28 August 2023, Mr Aaron Lee Taylor died between 7.30pm on the 27 August 2023 and 6am on the 28 August 2023, in a cell on the premises of HMP Garth, 1 Moss Lane, Ulnes Walton, Leyland. .
Taking into account the three letters that Mr Taylor wrote, the preplanning and method in which Mr Taylor died, leads us to conclude Mr Taylor did take steps intending to take his own life.
There were multiple failures in the measures taken to prevent self-harm and suicide. From the evidence that has been presented in court, multiple opportunities were missed by multiple professionals (nurse, GP, prison officers, mental health nurse, Prison Offender Manager, Governor, Senior prison officer) to support or offer suitable/appropriate care and resources for Mr Taylor. Inadequate preventative steps and assessments, lack of documentation, inability to adhere to policies and procedures and a 'lack of professional curiosity' as stated by an Operations Manager from GMMH who undertook an external investigation. All contributed to Mr Taylor's death.
Witness testimony from a prison officer demonstrated that the relevant observations had not been carried out on the 28 August 2023. With the evidence and testimony of the pathologist, and the uncertainty surrounding time of death, we cannot say that these observations or lack of, contributed to Mr Taylor's death.
As highlighted by the external investigation carried out by GMMH, there were multiple serious failures to provide minimal/adequate mental health interventions for Mr Taylor. These serious failures and inadequacies possibly contributed to Mr Taylor's death..
Circumstances of the Death
Mr Taylor was discovered in his cell on 28 August 2023 by a prison officer. He was found suspended from a ligature.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.