Oxleas NHS Foundation Trust

PFD Addressee
Reports: 26 Earliest: Dec 2014 Latest: 24 Mar 2026

43% 2-year response rate (below 83% average). 52% of classified responses show concrete action taken.

Response Status (last 2 years, 7 reports)
Responded 3 No Response 2
AI Classification
Action Taken 52%
Action Planned 35%
Noted 13%
Disputed 0%
Based on 46 classified responses
PFD Reports Received by Quarter
Clear
PFD Reports
13 results
Azroy Dawes-Clarke
All Responded
2025-0389 29 Jul 2025 Kent and Medway
State Custody related deaths
Concerns summary (AI summary) There was a significant lack of inter-agency dialogue and learning following a severe incident, leading to persistent confusion regarding command primacy and effective response strategies during acute medical emergencies in prison.
Action Planned (AI summary) A Practice Development Nurse (PDN) was appointed in September 2024 to ensure healthcare staff remain current with training and guidance, and the Quality Manager has reviewed and updated policies, communicating their locations to all staff members. SECAmb has several actions planned, including: establishing a Prisons Task and Finish Group, communicating the move away from 'Code Red/Blue' terminology, ensuring clarity around primacy of care, and undertaking a learning needs analysis regarding restraint implications. They will also review the Surrey Safeguarding Adults Board Care of Prisoners into Acute Hospitals guidance. HMPPS has reminded staff at HMP Elmley to request healthcare assistance immediately during any unplanned restraint and Oxleas staff have been reminded of their contractual requirement to remain with the individual throughout the medical emergency. NHS England Health & Justice guidance has been shared with Use of Force Coordinators and will be included in the new HMPPS framework and guidance.
Sheldon Jeans
All Responded
2025-0376 25 Jul 2025 Dorset
Alcohol, drug and medication related deaths State Custody related deaths
Concerns summary (AI summary) The absence of clear national and local policies on managing illicitly brewed alcohol ("hooch") and governing prisoner-held medications creates significant safety risks within the prison estate.
Noted (AI summary) HMP Guys Marsh has developed its Incentivised Substance Free Living (ISFL) unit, provides comprehensive staff information on illicitly brewed alcohol, and ensures in-cell medication safes are available and fit for purpose. Oxleas NHS Foundation Trust has committed to introducing regular assurance checks for all prisoners in receipt of IP medication. Oxleas NHS Foundation Trust will be developing and distributing new health promotion materials to the prison population at HMP Guys Marsh focusing on safe storage and proper disposal of medication. They have published a local In-possession Medication Compliance procedure outlining bi-monthly in-cell compliance checks. HMPPS has developed and disseminated materials focused on illicitly brewed alcohol (IBA), including the Drugs in Prison and Probation (DiPP) guide. The healthcare provider at HMP Guys Marsh, Oxleas NHS Foundation Trust, has committed to introducing regular assurance checks for all prisoners in receipt of IP medication, and in-cell lockers will be replaced if damaged. The Department acknowledges concerns about medication held in prisoners' possession, but states that national NHS policies for prisoners are the same as those used in the community. They believe existing processes, contractual monitoring, and learning from serious incidents are sufficient, and that national guidance could further complicate the issue.
Benjamin Harrison
All Responded
2024-0394 19 Jul 2024 Mid Kent & Medway
Alcohol, drug and medication related deaths State Custody related deaths
Concerns summary (AI summary) Lack of night-time healthcare in prison means untrained officers manage intoxicated prisoners without clear guidance, compounded by inconsistent information sharing policies between healthcare and prison staff regarding medication and risk.
Action Planned (AI summary) Oxleas will ensure the healthcare team is aware of relevant policies and that these are shared and discussed, and has updated on-call GP guidance. A review of policies has been completed and shared. HMPPS has issued an order to staff regarding escalating concerns about prisoners under the influence of illicit substances. They are also embedding a process for sharing information about at-risk prisoners with medication in their possession, and are consulting on new guidance around prisoners under the influence.
Luke Whitelaw
All Responded
2023-0486 27 Nov 2023 Inner North London
Suicide
Concerns summary (AI summary) Missed opportunities for urgent psychiatric review and readmission occurred, alongside a lack of "professional curiosity," poor documentation, and inadequate risk assessment formulation in patient care.
Action Taken (AI summary) Oxleas NHS Foundation Trust updated its Acute Mental Health Patient Flow and Bed Management policy in December 2023, and introduced a single crisis assessment form on 22 January 2024. They also reinforced documentation standards and protected time for complex case discussions, with clinical leadership and psychology support.
Samuel Pearson
All Responded
2022-0358 10 Nov 2022 South London
Alcohol, drug and medication related deaths
Concerns summary (AI summary) Multi-agency support failed during an emergency housing move for a vulnerable patient, exacerbating anxiety. A GP referral for mental health support was delayed by a long backlog, with referrers unaware of the service's capacity issues.
Action Planned (AI summary) Oxleas NHS Foundation Trust has completed a new ADAPT Operational Policy that clearly sets out expectations of information to service users and referrers regarding waiting times. An automated email will be generated and sent to the referrer informing them of expected screening times and contact information for urgent escalations. The London Borough of Bromley Council will be notified as soon as possible in the event of future emergency decants, when a vulnerable person subject to social care involvement is moved and London Borough of Bromley’s largest provider Clarion has been asked to review their Emergency Decant Policy around notification of emergency decants to LBB where there is a vulnerable household member. Clarion Housing Group is reviewing its alternative accommodation and related assessment process, considering how interagency working can be further embedded into its processes. The review is expected to be completed by 31st January 2023.
Liridon Saliuka
All Responded
2022-0355 8 Nov 2022 Inner South London
State Custody related deaths Suicide
Concerns summary (AI summary) There was a lack of clear, accessible documentation detailing a prisoner's disability adjustments and a general lack of disability awareness among prison staff, leading to inappropriate assumptions about his capabilities.
Action Planned (AI summary) Oxleas NHS Foundation Trust will now document adjustments required for a patient's disability on the Prison Nomis (P-Nomis) system, accessible by prison staff, healthcare, and social services. A fortnightly meeting involving all providers has now convened allowing discussion of patients presenting with disability that may be of concern, to facilitate improved care planning and communication. HMP Belmarsh will be holding monthly training sessions throughout 2023, alongside Oxleas NHS Trust and RGB, for all operational staff. These sessions will focus on encouraging staff to think differently about disability and to improve how they engage with disabled prisoners.
Bradleigh Barnes
All Responded
2022-0332 24 Oct 2022 Dorset
State Custody related deaths Suicide
Noted (AI summary) A memorandum of understanding has been put in place between healthcare and the prison regarding attendance of healthcare and all planned use of force interventions and healthcare staff are to be trained alongside prison officers. NHS England will request assurance from regional Directors of Commissioning that actions regarding the use of the PSA (proactive systematic assessment) vital signs tool have been implemented and evidenced by April 2023. They will also work with HMPPS on their review of PSO 1600: Use of Force, providing clinical leadership on section 6. HMPPS implemented a memorandum of understanding with the new healthcare provider at HMP Portland regarding the role of healthcare during use of force incidents. Whitewood furniture beds have replaced metal bedframes at HMP Portland. The Governor of HMP Portland confirms their involvement in the HMPPS response to the Regulation 28 report.
Claire Lilley
All Responded
2020-0297 11 Dec 2020 Inner London South
Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths Suicide
Concerns summary (AI summary) Risk assessments for Mental Health Act patients on Section 17 leave are fragmented across different records and tools, lacking a central, formulated document for comprehensive clinician review.
Action Planned (AI summary) Oxleas NHS Foundation Trust will require consistent recording of service users' and carers' feedback in the MDT template, make risk decisions at every MDT meeting, assign responsibility for updating risk assessments after each MDT, and update the Clinical Risk Assessment and Management Policy accordingly. The Medical Director and Director of Nursing will communicate these standards to all clinicians, facilitated by a team approach to risk management led by Matrons.
Viktor Scott-Brown
All Responded
2020-0163 18 Aug 2020 County Durham and Darlington
Community health care and emergency services related deaths Suicide
Concerns summary (AI summary) A psychiatrist failed to inform a patient about Lamotrigine's self-harm/suicide side effect due to a lack of awareness, exacerbated by inconsistent or absent warnings in reputable pharmacological guidelines, posing patient safety risks.
Noted (AI summary) Oxleas NHS Foundation Trust states they no longer have any involvement in the authorship or editing of the Maudsley Prescribing Guidelines since April 2015. Tees Esk & Wear Valley NHS Foundation Trust is developing a Medication Safety Series document regarding prescribing resources and sources of patient information, aiming to have a draft ready for approval on 24th September 2020 and complete dissemination by 2nd October 2020. NICE has passed the concerns regarding lamotrigine to the BNF publishers and will consider moving a footnote about the risk of suicidal thoughts and behaviour into the recommendation of their guideline on epilepsies, currently being updated. BNF Publications will add suicidal ideation as a side effect to the lamotrigine monograph and the important safety section of the lamotrigine monograph in the BNF.
Gary Etherington
All Responded
2020-0134 26 Jun 2020 Inner South London
Community health care and emergency services related deaths Mental Health related deaths Suicide
Concerns summary (AI summary) Mental health assessment failed to gather corroborative history and discharged patient to GP care without adequately considering suicidal ideation or providing a proper safety plan. The Root Cause Analysis was unreliable, failing to identify these critical care problems.
Action Taken (AI summary) The Trust has updated its Incident Management Policy and Procedures, implemented a new Serious Incident Team, and provided training on Mental Health Act assessments to address the coroner's concerns. They have implemented measures to ensure investigations are thorough and identify problems in care.
Jennifer Lewis
All Responded
2019-0003 15 Apr 2019 Kent (North-West)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) There was a failure to coordinate care between mental and physical health doctors, resulting in unsuitable and inadequate care for the patient's overall needs.
Action Taken (AI summary) The Trust has implemented several changes, including inviting relevant healthcare professionals to CPA meetings, entering all patients' weight and height into the Malnutrition Universal Screening Tool (MUST), and ensuring patients with long-term nutritional needs remain open to the dietician. These improvements are incorporated into the physical health strategy.
Michael Vukovic
All Responded
2018-0031 29 Jan 2018 London Inner (South)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The patient was discharged from psychiatric admission without follow-up, as the Home Treatment Team never saw him and a referral to a drug and alcohol service was not followed up by the hospital.
Noted (AI summary) Oxleas NHS Foundation Trust states that Mr. Vukovic was not referred to the Home Treatment Team and explains why. They note that Lifeline would not have been able to provide support and state Mr. Vukovic was discharged to a family who had been involved in his care.
Alex Kelly
All Responded
2014-0555 28 Dec 2014 Mid Kent & Medway
State Custody related deaths
Concerns summary (AI summary) A vulnerable child was sentenced without forensic psychiatric assessment, and mental health support conflicted with disciplinary procedures, failing to adopt a holistic approach or consult outside agencies. A social worker allocation was also significantly delayed.
Action Taken (AI summary) Tower Hamlets Council details actions taken following a Serious Case Review, including maintaining social worker numbers and updating a protocol with the Youth Offending Service to clarify responsibilities when a young person receives a custodial sentence. They also highlight increased awareness among Social Work staff due to the Legal Aid, Sentencing and Punishment of Offenders Act 2012. Central and North West London NHS Trust (CNWL) describes its Health and Wellbeing Team's structure and processes, including mental health assessments and improved office space and IT access. They state that all clinical contact is recorded on Systm1, with line managers checking staff entries and annual record keeping audits to monitor documentation standards, and training provided to new team members for Systm1 use. Oxleas NHS Foundation Trust describes implementation of the CHAT tool for assessing new arrivals at HMPYOI Cookham Wood, with training and monitoring standards. They detail information governance training for staff and supervised medication dispensing procedures, including recording and reporting non-compliance. The Medway Youth Offending Service (YOT) describes actions taken in response to the coroner's concerns including ACCT training for the Resettlement Team, enhanced reviews overseen by a Governor, and submission of early release paperwork. They also detail procedures for initial planning meetings, maintaining contact, and final release meetings according to YJB National Standards. The Ministry of Justice outlines reforms in the Young People's Estate, including a standardised casework model, enhanced regimes, and changes to ACCT procedures. They detail night operating procedures and confirm that an information sharing protocol between relevant agencies at HMYOI Cookham Wood is being formulated.