Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Declan Lewis Carr who died on 28 August 2023.

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 20 October 2025 concerning the death of Declan Lewis Carr on 28 August 2023. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Declan’s family and loved ones. NHS England is keen to assure the family and yourself that the concerns raised about Declan’s care have been listened to and reflected upon.

I am grateful for the further time granted to respond to your Report, and I apologise for any anguish this delay may have caused to Declan’s family or friends. I realise that responses to Coroners’ Reports can form part of the important process of family and friends coming to terms with what has happened to their loved ones, and I appreciate this will have been an incredibly difficult time for them.

Your Report raised concerns around psycho-social support and the handover of care to the support services in prison. Your Report also raised concerns around the lack of a national policy allowing prisons to share information about those receiving psycho- social support when transferring prisoners, and the lack of continuity of care for prisoners receiving psycho-social support for drug misuse. Prison continuity of care refers to a structured process that ensures individuals maintain access to healthcare services, such as physical health, mental health, substance misuse treatment, and social care as they move between prison settings or transition back into the community.

To provide assurance in relation to the sharing of all healthcare appointments, including psycho-social related support, NHS England can confirm that when a patient transfers between prisons their clinical record will transfer with them, meaning that healthcare workers at the receiving prison will be able to access details including the prisoner’s medical history, prescribed medication, services currently being accessed and any appointments.

If the psycho-social service provider had been inputting information into the main clinical system at HMP Hull, then HMP Humber would have had access to the records National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

2nd January 2026

when Declan was registered onto their clinical system, which should have happened when he was received into HMP Humber. Once registered onto the clinical system, full record sharing takes place. Unfortunately, this did not happen in Declan’s case.

A review of the NHS England Health and Justice service specifications is being undertaken by NHS England through 2025 to 2026, and any learning from this case will be used to inform this review.

The findings, information and any learning from this case will also be listed for discussion at a future NHS England Health and Justice Delivery Oversight Group (HJDOG). The HJDOG is the senior leadership forum, which holds responsibility for the oversight of delivery and continuous improvement in Health and Justice commissioned services, through both national and regional teams. All health and justice related Reports to Prevent Future Deaths are shared and discussed at the HJDOG, and assurance is sought from regions where learning and action is identified.

Prison continuity of care refers to maintaining a prisoner’s health services throughout their time in the system, including during transfers and after release. Key aspects include coordinating with healthcare providers, improving internal prison policies, preparing patients for release and linking them to community services including substance misuse treatment. Efforts are made to address barriers to care and ensure seamless transitions, although challenges remain.

Key elements of prison continuity of care

Key aspects of Continuity of Care include:

1. Seamless Healthcare Transition - ensuring that upon release, individuals have access to timely, appropriate follow up care, such as substance misuse treatment or mental health services which are typically arranged within a designated timeframe. (Continuity of care between prison and the community: self-assessment tool guidance - GOV.UK)

2. Care coordination pre and post release - programs like NHS England’s RECONNECT arrange pre-release engagement (up to 12 weeks) and post-release support (up to 6 months) offering liaison, referral, advocacy, and a named staff member to ensure a safe transition into community healthcare. (NHS commissioning » RECONNECT)

3. Maintaining treatment during custody transfers - within prison, continuity refers to maintaining ongoing healthcare; primary, secondary, mental health, dental, despite internal transfers, court appearances, or remote health appointments. This includes sharing health records and managing logistical barriers like escorts or security protocols. Prison Health providers and Prison services need to coordinate secondary care appointments with Hospital Trusts to ensure timely coordination of hospital appointments based on the individual’s clinical needs and reason for referral to specialist services. This is to ensure that the prison service can enable patients to their appointment whilst maintaining public protection and security arrangements, considering the different security parameters that each prison may pose – i.e. Category A High Security prisons, Category C Resettlement Prisons.

Prison officers will still be paid as the escorting of an external appointment will usually be part of their rostered shift. (Continuity of care between prison and the community: self-assessment tool guidance - GOV.UK; Healthcare provision in prisons: continuity of care)

4. Holistic health management - recognising the high prevalence of complex health and social care needs such as substance dependency, mental illness, infectious diseases, and unstable housing. Continuity of care extends beyond clinical treatment to include support for social determinants of health. (Healthcare provision in prisons: continuity of care; Continuity of care between prison and the community: self-assessment tool guidance - GOV.UK; NHS commissioning » RECONNECT) Continuity of care is improved in a number of different ways, including the following:
• Inter-agency collaboration: Prisons, the NHS and the Probation service must work together to align healthcare needs with available resources. Please refer to the National Partnership Agreement for Health and Social Care for information relating to Inter-Agency Collaboration, which is a signed agreement between a number of agencies outlined on Page 25.
• Policy and process updates: Embedding guidance into practice, such as the Prison Service Order 3050 and Physical Health of People in Prison guidance to include clear communication protocols for transfers and release is crucial.
• Improved communication: Healthcare and prison staff need to share information effectively to ensure a patient’s needs are met without delay, as highlighted by the Health Services Safety Investigations Body (HSSIB).
• Prisoner engagement: Educating prisoners about their health needs and encouraging them to attend appointments can increase engagement and lead to better outcomes.
• Dedicated support services: Programs like RECONNECT provide non-clinical support including advocacy and signposting to help individuals connect with community health services after release.
• North East and Yorkshire regional colleagues have advised that HMP Hull and HMP Humber have introduced a local policy to share information about prisoners receiving psycho-social support during transfers between these two establishments, and this pathway was developed and embedded following learning from Declan’s death.

There are nationally agreed clinical templates embedded on SystemOne, which is an electronic patient medical record system. One of these templates is specific to Court, Release and Transfer Out screening. A copy of the template has been attached with this response. The purpose of national agreed templates is to ensure standardised healthcare delivery aligned with National Institute for Health and Care Excellence (NICE) guidance and key performance indicators.

Whilst it is recognised that, in this case, the prison healthcare providers developed a local policy to support with continuity of care; national templates are mandated to support with information sharing and this is monitored through key performance indicators in regional contract management. In Declan’s case, the national template was completed, however he had denied any substance or alcohol misuse upon reception screening in HMP Humber following transfer. Declan, as with all new prisoners into HMP Humber, had an induction to the prison where he was made aware of Change Grow Live (CGL) and their service offer, including information on how to self-refer should he require support.

For assurance, an audit on the continuity of care between HMP Hull to HMP Humber for those in service with CGL not prescribed opioid substitution therapy was conducted for transfers in June 2025. This audit confirmed that:
• There were 11 non-prescribed service users transferred from HMP Hull to HMP Humber
• 100% of those had a referral opened as per the Non-Clinical Prison to Prison Transfer (H&H) Pathway upon arrival at HMP Humber.
• 45.5% declined entry into the service and their referrals were closed.
• 9% signed into the service and completed an initial assessment, however they dropped out at the next intervention.
• 45.5% signed into the service and for continued care.

A second audit will be completed against the same parameters in January 2026. There was no action plan attached to the audit, as the findings showed that the pathway was being followed correctly and 100% of those transferred from HMP Hull were picked up and a referral opened in HMP Humber. I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Declan, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.

Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.