HM Prison and Probation Service

PFD Addressee
Reports: 154 Earliest: Aug 2013 Latest: 24 Mar 2026

53% 2-year response rate (below 83% average). 56% of classified responses show concrete action taken.

PFD Reports
154 results
Kirsten Hocking
Partially Responded
2024-0617 11 Nov 2024 West Sussex, Brighton & Hove
State Custody related deaths
Concerns summary (AI summary) There is a critical lack of specialist rehabilitation accommodation for women at high risk of self-harm, leading to ineffective post-release support. Probation officers also lack sufficient understanding of available housing options and appropriate release planning.
Action Planned (AI summary) Steps2Recovery has implemented several measures including clarity in communication, improved referrals, reconsideration policies, leadership experience, policy reviews, staff training, and enhancements to its case management system. The Probation Service is promoting community disposals and engaging with regional female leads to promote Approved Premises placements for women with complex needs; Female AP briefings for practitioners will emphasize this point from September.
Stephen Sleaford
Partially Responded CC
2024-0550 14 Oct 2024 Leicester City and South Leicestershire
State Custody related deaths
Concerns summary (AI summary) There's a severe lack of first aid and CPR training for prison officers, including new recruits, creating critical response gaps. Routinely obscured cell observation panels and unclear guidance on emergency cell entry further compromise prisoner safety.
Action Taken (AI summary) HMPPS re-issued the First Aid Policy Framework in August 2023, re-issued a notice to staff in October 2024 reminding them of the importance of challenging prisoners who block their observation panels, and issued a new film, ‘Responding to emergency situations’.
Ian Deavall
Partially Responded
2024-0485 9 Sep 2024 Greater Manchester West
State Custody related deaths
Concerns summary (AI summary) A significant risk exists in HMP Forest Bank due to emergency cell bells being easily deactivated by other prisoners, potentially delaying critical medical responses.
Action Taken (AI summary) HMP Forest Bank has split the induction across two wings, housing vulnerable prisoners and non-vulnerable prisoners separately, eliminating the risk of cell call bells being cancelled by other prisoners. Plans for future investment with regards to the cell call system will be determined by the competitions process and award of future contracts.
Kevin McDonnell
All Responded
2024-0433 7 Aug 2024 Nottingham City and Nottinghamshire
State Custody related deaths Suicide
Concerns summary (AI summary) Prison staff failed to conduct meaningful ACCT observations and share critical risk information for at-risk prisoners. Furthermore, there was a failure to secure and retain accurate documentary evidence following a death in custody.
Action Taken (AI summary) HMP Nottingham has increased SASH/ACCT awareness training for staff and introduced a 'trigger' database for sharing pertinent risk information. ACCT books are no longer removed from the wing during quality checks to ensure contemporaneous entries.
Leah Croucher
Partially Responded
2024-0445 1 Aug 2024 Milton Keynes
Other related deaths
Concerns summary (AI summary) Inadequate monitoring of a known sex offender under probation and police supervision, coupled with poor inter-agency information sharing, allowed him to breach terms and commit murder.
Action Planned (AI summary) The Probation Service will conduct a fundamental review of the process for monitoring sex offenders and information sharing, focusing on the Thames Valley area and including consultation with partner agencies, with completion expected by March 31, 2025.
Matthew Braben
No Identified Response CC
2024-0423 1 Aug 2024 West London
State Custody related deaths Suicide
Concerns summary (AI summary) Inadequate recognition of childbirth as a mental health risk factor, poor ACCT process and staff training, and prolonged cell confinement due to gym instructor shortages significantly harmed prisoner mental health.
Lee Purkis
All Responded
2024-0418 1 Aug 2024 West Sussex Brighton & Hove
Other related deaths
Concerns summary (AI summary) A mental health treatment requirement (MHTR) imposed by the Crown Court was not communicated to the Trust treating Lee Purkis, leading to his discharge without their awareness of it; probation should ensure all involved in administering the requirement are aware of it.
Action Planned (AI summary) The Probation Service acknowledges responsibility for MHTR oversight and is piloting Secondary Care MHTR "Proof of Concept Sites" with NHS England to improve assessment and practice. In Kent, they are collaborating with the Forensic and Specialist Directorate to upskill staff on MHTR processes.
Zara Aleena
All Responded
2024-0409 26 Jul 2024 East London
Other related deaths
Concerns summary (AI summary) Severe understaffing within the probation service led to poor quality risk assessments, inadequate staff training, and ineffective risk management. Additionally, the existing risk assessment tool and alert systems proved to be unwieldy and ineffective.
Action Planned (AI summary) London Borough of Redbridge details existing CCTV operator training which includes modules on behavioural body language training designed to detect suspicious behaviours. They also describe how they ensure risks for lone females are considered when planning events. The Metropolitan Police Service acknowledges the reviews lacked rigor. To address this, they will implement recommendations from an independent review, introduce body-worn video, review the integrated offender management system and implement Proactive Management Plans and have developed a new process map for clarity around recalls to prison. The Home Office acknowledges the concerns and will consider how to encourage business owners and staff to report predatory behavior. They mention plans to target perpetrators and address the causes of abuse and violence. HMPPS and MoJ acknowledge staffing issues and communication failures, but highlight the Prioritisation Framework implemented in January 2022. They also mention the Integrated Offender Management (IOM) guidance update (V4.1) from August 30, 2024, which explicitly requires POMs to be invited to all multiagency case conferences to improve communication.
Yuri Hatton
No Identified Response CC
2024-0608 11 Jun 2024 Inner West London
State Custody related deaths
Concerns summary (AI summary) Many prison OSGs lacked official training, first aid training records were insufficient, and crucial prison-specific training for recognising unconsciousness had not been implemented.
Daniel Beckford
No Identified Response CC
2024-0607 11 Jun 2024 Inner West London
State Custody related deaths Suicide
Concerns summary (AI summary) Prison officer first aid training lacked clarity on using rescue breaths during resuscitation, conflicting with current Resuscitation Council UK guidance.
Frazer Williams
Partially Responded
2024-0294 31 May 2024 Dorset
State Custody related deaths Suicide
Concerns summary (AI summary) A high-risk mental health patient was inappropriately transferred to a prison with limited healthcare and no effective handover. The absence of a national directory for prison healthcare facilities exacerbated risks for prisoners with complex needs.
Noted (AI summary) NHS England is responding to 'The Long Wait' HMIP report, and is working with HMPPS nationally and regionally to support the ACCT process. HMP Guys Marsh issued guidance to healthcare staff and relevant training was provided to induction and reception staff who conduct first night interviews. NHS England South West region supported the development of e-learning training for healthcare staff on safeguarding in secure and detained settings. Unilink will raise the issue of prisoner transfer information with the Ministry of Justice to explore the possibility of sharing relevant information to better manage and redirect communications. The response is a cover letter forwarding the PFD response, but contains no details itself. The Department of Health and Social Care acknowledges concerns about mental health treatment equity in prisons and delays in transferring mentally unwell prisoners. They mention the Mental Health Bill, which will introduce a 28-day statutory time limit for transfers from prison to hospital, and that they expect other recipients of the report to address concerns around national guidance, ACCT processes and engagement with family members.
Luke Pearce
Partially Responded
2024-0270 16 May 2024 Staffordshire and Stoke on Trent
Suicide
Concerns summary (AI summary) Staff lack timely training and guidance on appropriate cell entry during medical emergencies and correct use of Code Blue/Red communications, risking delayed or improper responses.
Action Taken (AI summary) A new national video on medical emergency procedures, including entering cells and using emergency codes, was launched in January 2024 and made available to all HMPPS staff. The Governor of HMP/YOI Swinfen Hall has been showing the video to existing staff as part of Safety Critical training with the goal of completion by March 2025.
Scott Rider
All Responded
2024-0210 12 Apr 2024 Milton Keynes
Suicide
Concerns summary (AI summary) The indefinite nature of IPP sentences traps prisoners, leading to feelings of hopelessness and challenging behaviours, raising concerns about inhumane treatment and future deaths if not reviewed.
Action Planned (AI summary) HMPPS acknowledges concerns regarding Imprisonment for Public Protection (IPP) sentences and highlights the Government's plans to reform legislation relating to the termination of the licence for IPP offenders by making amendments to section 31A of the Crime (Sentences) Act 1997, which provides for the termination of IPP licences. They mention the Bill has not received Royal Assent and is currently being scrutinised by the House of Lords.
Jacob Billington
All Responded
2024-0136 13 Mar 2024 Birmingham and Solihull
Other related deaths
Concerns summary (AI summary) Release of high-risk prisoners is jeopardised by inadequate interagency communication, fragmented information systems, and a lack of clear guidance and understanding for discharge planning roles.
Noted (AI summary) West Midlands Police have updated their systems with prompts to improve the identification of those at increased risk and will work with MAPPA partners to ensure the coordinator role and new policy are understood and cascaded to relevant staff. HMP & YOI Parc has provided notice to offender managers to notify the relevant Community Offender Manager when a prisoner is being released at sentence end date and will be of no fixed abode, including providing information relating to a prisoner’s intentions in terms of where they are going on the day of release. G4S will continue to streamline its own data recording, to ensure as much information as possible is shared through the primary national prisons IT system, DPS. BSMHFT will develop a sustainable engagement strategy with MAPPA, review the Prison Discharge Coordinator's role, and explore amendments to the Systemone interface in HMP Birmingham to record community mental health team involvement, anticipating a decision within a month. The health board acknowledges the concerns raised in the report but states that it has no jurisdiction/power over the actions required for some of the concerns. However, it has alerted the MAPPA Coordinator to the concern regarding release of high-risk prisoners and will participate in Strategic Management Board discussions. West Midlands Probation Service is working with NHS-England Reconnect Service to ensure Probation Practitioners are aware of how to refer into this service in Prison for support “through the gate”, the transition period from prison into the community. West Midlands Probation Service will work with the Health Trust to support any Guidance revisions undertaken by the Health Trust to ensure that the Guidance is clear and enables effective information sharing and can be embedded within and understood by all in the Probation Service.
Giuseppe Tabone and Andrew Evans
All Responded
2024-0134 12 Mar 2024 East Sussex
Alcohol, drug and medication related deaths
Concerns summary (AI summary) Prison staff failed to perform mandatory roll checks, with falsified records and confusion over requirements, creating a risk of undetected prisoner medical emergencies.
Action Taken (AI summary) HMP Lewes investigated and disciplined staff who failed to carry out roll checks, and has planned further 'bite size' training sessions on roll checks with support from the standards coaching team. Staff are aware of the potential for disciplinary procedures if they fail to uphold prisoner safety.
Liam Turner
All Responded
2024-0055 5 Feb 2024 Manchester City
Alcohol, drug and medication related deaths
Concerns summary (AI summary) It is not mandatory for prison officers to maintain up-to-date basic first aid and CPR training, leaving a significant proportion of staff without current life-saving skills.
Action Taken (AI summary) HMPPS re-issued the First Aid Policy Framework in August 2023, highlighting training requirements and the need for risk assessments to determine adequate numbers of trained staff. HMP Manchester issued guidance and a presentation in December 2023 to all staff on when CPR is appropriate.
Kane Boyce
All Responded
2024-0034 17 Jan 2024 Nottingham and Nottinghamshire
Alcohol, drug and medication related deaths State Custody related deaths
Concerns summary (AI summary) Prison staff deliberately ignored cell bells, lacked policy for isolating cell power, failed to follow "under the influence" protocols, and misunderstood key date suicide risk, highlighting systemic safety failures.
Action Planned (AI summary) Sodexo states that the MOJ have confirmed that all managers, including the Senior Leadership Team, are to undergo the national ACCT training as a matter of urgency, this will include ACCT Assessor training and case manager training. When the operational management of the prison returns to Sodexo all staff will undergo ACCT refresher training, if not done before. HMPPS issued guidance and a standard template for Early Learning Reviews (ELRs) in 2021, held a workshop with Group Safety Leads (GSLs) in July 2022, and another in April 2024 to offer additional upskilling. They will mandate the early learning review process in PSI 64/2011 and issue a revised standard template and refreshed guidance document.
Trevor Monerville
All Responded
2024-0025 16 Jan 2024 East Sussex
State Custody related deaths
Concerns summary (AI summary) The prison failed to adequately monitor and manage a patient's epilepsy with no seizure care plan or effective communication between healthcare and prison staff, compounded by a lack of staff training.
Action Taken (AI summary) Practice Plus Group details changes including medicines management policies reviewed and updated, a new audit tool for medication administration, new roles for nurses to oversee patients on wings, and a process in place if patient might be stockpiling medication. HMPPS has provided training to staff regarding the ACCT process, established a Safety Intervention Meeting (SIM) and a Multi-Disciplinary Complex Case Clinic (MPCCC) for complex cases. They encourage prison and healthcare staff to report intelligence through the Mercury intelligence system and undertake First Aid needs assessments and training.
Stephen Coster
All Responded
2024-0146 4 Jan 2024 East Sussex
State Custody related deaths
Concerns summary (AI summary) Inadequate prison healthcare assessment, observation, and care planning, coupled with poor communication and prison staff's lack of understanding of emergency transfer protocols, led to significant delays.
Action Taken (AI summary) HMP Lewes reviewed record-keeping practices, clarified responsibilities for welfare checks and clinical observations, regularly briefs staff on emergency codes, and reviewed hospital escort procedures. Custodial managers now oversee Code Blue/Red incidents, and the policy on emergency escorts is being actively reviewed.
Wyndham Thomas
All Responded
2023-0547 21 Dec 2023 Nottingham City and Nottinghamshire
State Custody related deaths Suicide
Concerns summary (AI summary) The absence of in-cell ligature point risk assessments, ligature point maps, and mandatory "Safer Cells" in prisons creates critical missed opportunities to prevent self-harm by ligation.
Action Taken (AI summary) HMPPS has implemented a revised ACCT case management approach across the prison estate to improve support for prisoners at risk of self-harm or suicide. They are also developing a safety training package for staff which will improve understanding of suicide and self-harm prevention.
Martin Willis
All Responded
2024-0171 19 Dec 2023 Shropshire, Telford and Wrekin
Suicide
Concerns summary (AI summary) The ACCT procedure was not properly implemented or supervised, including false entries and omissions. Concerns remain regarding correct observation levels and the need for an inter-agency review of mental health care provided in prison.
Action Planned (AI summary) The trust states that the coroner's concerns have informed the development of a Health in Justice Suicide Prevention Plan, including a multi-agency Suicide Prevention Forum, and will share the results of an inter-agency review with staff and partners. Completion is expected by September 2024. Following an inter-agency review, the trust is implementing actions including refresher training, improving the ACCT procedure, updating risk assessment documentation, and reviewing procedures for transferring prisoners to establishments with hospital wings. Various completion timescales are provided, ranging to September 2024. HMPPS will present an operational briefing to staff on responsibility for ACCT checks. They have updated Case Co-ordinator processes, and are sharing QA with managers, and meeting with partner agencies to relay responsibilities.
Samuel Jones
All Responded
2023-0499 5 Dec 2023 Dorset
State Custody related deaths
Concerns summary (AI summary) Prison and healthcare record systems failed to flag critical "trigger dates" for vulnerable prisoners. Staffing shortages prevented thorough record review, and system limitations meant crucial information was frequently overlooked.
Noted (AI summary) HMPPS will revisit recording key dates as it continues to develop the Digital Prison Services (DPS), and it anticipates the ability to search for key words will be available by 2025. It will also issue a Senior Leaders Bulletin on the importance of recognising key dates and encouraging the use of local databases. NHS England describes the Health and Justice Information Service (HJIS) and options for flagging key dates, and refers to NICE guidance on managing medicines. It states that responsibility for cell searches lies with HMPPS. The Ministry of Justice acknowledges the concerns raised and states that HM Prison and Probation Service (HMPPS) will respond to the operational issues; the Minister endorses the HMPPS response.
Manoel Santos
Partially Responded
2023-0361 3 Oct 2023 Inner South London
State Custody related deaths Suicide
Concerns summary (AI summary) Delays in notifying foreign national offenders of immigration detention and inadequate access to legal advice are compounded by poor inter-agency communication and a lack of specialist prison staff for immigration matters.
Action Taken (AI summary) The Home Office has implemented new commissioning and handling processes and established a Strategic Improvement Operations team within FNORC to log, review, and track recommendations from internal and external investigations, ensuring risks are managed consistently. They also use a specific form called ‘Request for Risk Information’ to request an OASys assessment. These are now centrally administered by the FNO coordination hub to ensure that there is a central referral point for the Home Office. The request is then sent directly to the relevant practitioner to action, or the team if the matter is not yet allocated. An escalation process that highlights responses that have not been received within 20 days has also been introduced. Practice Plus Group has implemented weekly and fortnightly meetings between healthcare management and prison governors to improve communication between agencies. They have also clarified the established process regarding concerns for a prisoner's safety, where officers should inform a member of the healthcare team if they are presence. HMPPS has re-issued a notice to staff at HMP Belmarsh clarifying procedures for unlocking cell doors during the night state, emphasizing preservation of life takes precedence. Additionally, learning from probation-involved inquests will be disseminated across the probation service, and included as part of the Offender Management in Custody (OMiC) model of working.
Haik Nikolyan
All Responded
2023-0340 15 Aug 2023 Buckinghamshire
State Custody related deaths Suicide
Concerns summary (AI summary) HMP Aylesbury's transition to a Category C prison is challenged by recruitment and retention issues among experienced staff, impacting daily operations, training, incident response, and the management of vulnerable prisoners.
Action Taken (AI summary) HMP Aylesbury has improved staffing levels, expanded key work provision, appointed a Neurodiversity support manager, reviewed the adjudication tariff for drug-related incidents, and reconfigured the safety team. Nationally, a TV and radio advert has been launched to support recruitment.
Stephen Weatherley
All Responded
2023-0269 20 Jul 2023 Inner South London
Alcohol, drug and medication related deaths State Custody related deaths
Concerns summary (AI summary) Significant issues with data recording and retention in HMP Thameside led to lost critical documents and incomplete records, alongside the absence of a written drug swallow policy.
Noted (AI summary) HM Inspectorate of Prisons acknowledges receipt of the report but states its remit is limited to the inspection process, referring to published inspection reports and stating the information will inform future risk assessments at HMP Thameside. HM Inspectorate of Prisons acknowledges receipt of the report but states its remit is limited to the inspection process, referring to published inspection reports and stating the information will inform future risk assessments at HMP Thameside. Serco (HMP Thameside) details actions taken, including the introduction of MS Teams folders for data retention, enhanced security strategies with trained analysts, and the implementation of a bodyscanner, with learnings from the inquest shared with senior management. They will also share learnings of the inquest with the senior management team, with advice that where there is a suspected 'swallow' and absence of a positive bodyscanner result, they should re-locate to healthcare. HM Prison and Probation Service acknowledges the concerns regarding record keeping and data retention at HMP Thameside, confirms receipt of the prison director's response, and outlines the contract delivery indicators and monitoring processes in place.