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.

Response Status (last 2 years, 36 reports)
Responded 19 No Response 4
AI Classification
Action Taken 56%
Action Planned 32%
Noted 12%
Disputed 0%
Based on 203 classified responses
PFD Reports Received by Quarter
PFD Reports
154 results
Sean Heeney
All Responded
2023-0250Deceased 14 Jul 2023 Northamptonshire
Alcohol, drug and medication related deaths State Custody related deaths
Concerns summary (AI summary) Bridgewood House lacked a clear plan for safely extricating medically unwell or uncooperative residents from its first floor, compounded by the building's layout, leading to dangerous delays.
Action Planned (AI summary) Bridgewood House Approved Premises is consulting with the local emergency services on the preparation of a plan to deal with evacuation from the building in a medical emergency. A clearly recorded understanding between the agencies involved in such a procedure should ensure a successful evacuation should a similar situation arise in the future.
Liam Bentley
All Responded
2023-0227 3 Jul 2023 Mid Kent and Medway
State Custody related deaths Suicide
Concerns summary (AI summary) Critically low and predicted further reductions in prison staff complements compromised the safety of the deceased and pose an ongoing risk due to staff shortages.
Action Taken (AI summary) HMPPS is improving staffing at HMP Swaleside through interventions across pay, recruitment and retention, including a colleague mentor scheme, Advance into Justice, Prison Officer ‘Futures’, the National First Time Officer scheme, locally targeted PR activity, a market supplement and a pay increase.
Anthony Smith
All Responded
2023-0187 7 Jun 2023 Lancashire and Blackburn with Darwen
State Custody related deaths
Concerns summary (AI summary) The absence of protective mouth masks for resuscitation in prison exposes resuscitators to the risk of blood-borne viruses and could deter life-saving rescue breaths.
Action Taken (AI summary) The First Aid Policy Framework is being re-issued with instructions on face shield use, requiring all first aid kits to contain them and for them to be monitored. Face shields have been purchased and added to first aid boxes at HMP Preston, and staff were notified.
Andrew Dean
All Responded
2023-0178 2 Jun 2023 East Sussex
Suicide
Concerns summary (AI summary) There are no clear prison procedures for ensuring new prisoners can make initial family contact or for handling incoming calls from family members concerned about a prisoner's safety, posing a risk of future self-harm or suicide.
Action Taken (AI summary) HMPPS is rolling out electronic logging of safer custody concerns to all prisons by March 2024, with HMP Lewes receiving on-site support in December 2023. Staff have been instructed to record welfare calls and pass information to duty officers immediately.
Thomas Huntley
All Responded
2023-0461 14 May 2023 Hampshire, Portsmouth and Southampton
State Custody related deaths Suicide
Concerns summary (AI summary) Prison staff failed to comply with mandatory ACCT procedures and lacked understanding of risk factors, indicating poor training and audit quality. Inadequate information sharing between healthcare and prison systems also posed significant risks.
Action Taken (AI summary) HMP Winchester delivers monthly ACCT v6 and SASH training, reviews staff training needs, reinforces ACCT procedures, facilitates multi-disciplinary discussions, and reviews the use of SIM forms. A review of ligature-resistant cells is also underway nationally.
Michael Smith
Partially Responded
2022-0417Deceased 10 Nov 2022 County Durham and Darlington
State Custody related deaths Suicide
Concerns summary (AI summary) Insufficient staffing levels in the prison's segregation unit prevented critical medical and mental health assessments for a vulnerable prisoner. A delay in emergency response due to staffing shortages also put his life at risk.
Action Taken (AI summary) HMP Durham SACU staffing levels are above national benchmarking, overseen by a dedicated Custodial Manager. A full-time nurse is based within the SACU to provide more flexible healthcare input. HMP Durham will review its contingency plans to incorporate learning from this incident, to allow for appropriate deployment of staff should other incidents occur at the same time.
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.
Ezra Tamiem
Historic (No Identified Response)
2022-0220 19 Jul 2022 Bedfordshire and Luton
State Custody related deaths Suicide
Concerns summary (AI summary) A ligature point in a healthcare wing cell, not designed as a "safer cell," was used by the deceased and remains an unaddressed risk without plans for remedy.
Thomas Moffett
Partially Responded
2022-0018 22 Jan 2022 Lancashire and Blackburn with Darwen
State Custody related deaths
Concerns summary (AI summary) Persistent communication failures between prison healthcare staff and emergency control rooms during medical emergencies, a recurring issue across multiple prisons, indicate a potential national systemic problem.
Action Taken (AI summary) Spectrum CIC has held a meeting between the healthcare team, the Safer Custody Governor, and the Governing Governor at HMP Preston to develop a new system that ensures that healthcare staff are able to communicate efficiently with the prison control room and ambulance control. HMP Preston staff are to receive training in ambulance categorisation and the Governing Governor sent a Governor's Order clarifying the process in line with PSI 03/2013.
Mark Castley
All Responded
2021-0427 22 Dec 2021 London Inner South
Other related deaths Suicide
Concerns summary (AI summary) The coroner suggests the risks of recurrent impulsive self-harm were not fully assessed in light of the circumstances, specifically concerning the period after sentencing, and that a notification form might have been completed had the risks been fully considered.
Action Planned (AI summary) HMCTS is updating Security and Safety Operating Procedure 4b across all crime courts by the end of May, including publicising random searches and implementing a new Safeguarding policy with training for front line court staff to identify and escalate safeguarding concerns. The 'Working with Suicide & Self-Harm' guide was reviewed, changing a question about suicide risk, and the Probation EQUiP process map was updated for court staff; all London probation staff were reminded to adhere to the 'probation risk to self' EQUiP process maps. London Probation published a new thematic Suicide and Self-Harm Performance and Quality Newsletter on 19 January 2022.
Anthony Clacher
All Responded
2021-0356 22 Oct 2021 Dorset
Alcohol, drug and medication related deaths Mental Health related deaths Other related deaths
Concerns summary (AI summary) A national lack of guidance for welfare checks and monitoring prisoners under the influence of psychoactive substances poses significant risks of physical and mental health deterioration, including death.
Noted (AI summary) NHS England highlights that the Digital Person Escort Record (DPER) has been live across the prison estate since November 2020, and all reception healthcare staff should have access to the DPER prior to arrival of persons at the site; further a review and update of the reception and secondary screening templates for healthcare is ongoing. NHS Digital is considering the coroner's concerns about SystmOne in prisons when developing the capabilities for the HJIS re-procurement in 2022/23 and will consider adopting GP IT related products such as GP2GP and the Primary Care Registration Management system in FY22/23. The Department of Health and Social Care acknowledges the concerns raised, highlights the National Partnership Agreement for Prison Healthcare, and notes actions NHS England is taking regarding substance misuse in prisons. HMPPS is considering a national rollout of local initiatives (including those from HMP Guys Marsh) to improve welfare checks on prisoners under the influence of psychoactive substances, and is developing a new version of the ACCT (Assessment, Care in Custody and Teamwork) processes with revised training modules being rolled out nationally for all staff involved in the delivery of ACCT.
James Devenny
All Responded
2021-0179 25 May 2021 Mid Kent and Medway
Mental Health related deaths State Custody related deaths Suicide
Concerns summary (AI summary) Prisoners lack direct access to Samaritans, relying on staff, which is especially difficult for those with violence risks. Prison officers are not routinely briefed on prisoners' significant self-harm history.
Action Taken (AI summary) HMP Elmley has equipped nearly all cells with in-cell phones and ensures access to Samaritans. ACCT version 6 has been rolled out across the male estate and training modules and awareness materials have been made available to all staff. The prison also operates a Key Worker scheme and uses an updated safety diagnostic tool.
Kevin Lovatt
Partially Responded
2021-0012 15 Jan 2021 Staffordshire South
Alcohol, drug and medication related deaths Other related deaths
Concerns summary (AI summary) National training for prison staff lacks clear guidance on the safe use of force when prisoners have items in their mouths, posing a risk to breathing.
Noted (AI summary) NHS England and NHS Improvement outline the commissioning of healthcare into prisons is done on a principle of equivalence. They state Advanced Life Support is not appropriate for healthcare professionals working in prisons, as it may lead to staff working outside of their registered professional clinical competencies.
Andrew Jones
Historic (No Identified Response)
2020-0103 20 Apr 2020 Lancashire and Blackburn with Darwin
Alcohol, drug and medication related deaths Mental Health related deaths State Custody related deaths
Concerns summary (AI summary) The prison service demonstrated a reduced capacity for self-harm risk assessment, with failures in re-evaluating risk after significant patient changes, providing adequate pain management, and informing new wings of altered risk profiles.
Lewis Francis
All Responded
2020-0074 23 Mar 2020 Exeter and Greater Devon
Mental Health related deaths State Custody related deaths Suicide
Concerns summary (AI summary) A lack of mechanisms for transferring serious crime suspects in police custody to mental health facilities and insufficient understanding of autistic prisoners' needs pose significant risks.
Action Planned (AI summary) Wiltshire Police is working with other forces and the South West Provider Collaborative to develop a Memorandum of Understanding regarding mental health pathways. Avon and Somerset Police, on behalf of the South West Provider Collaborative, has clarified out-of-hours admission processes and confirmed with providers that services are commissioned to admit patients out of hours if clinically indicated. They are also developing a Memorandum of Understanding, with key milestones including governance/agency approval by October 2020 and communication to stakeholders by November 2020. They consider the training action is directed towards the Prison Service alone.
Robert Brown
All Responded
2020-0065 9 Mar 2020 Staffordshire (south)
Alcohol, drug and medication related deaths State Custody related deaths
Concerns summary (AI summary) Information in central NOMIS records, medical system records, and the security department was not available to all prison staff who may have benefitted from having it.
Action Planned (AI summary) NHS England and NHS Improvement are leading a project with HMPPS to implement inter-operability between SystmOne and NOMIS to improve information sharing; Phase one is delayed until August 2020 due to COVID-19 priorities, and Phase three is expected in 2021. The Safer Custody Zone at Dovegate was formed in 2019, to facilitate information sharing between prison and healthcare staff.
Carl Newman
All Responded
2020-0056 6 Mar 2020 Liverpool and the Wirral
State Custody related deaths Suicide
Concerns summary (AI summary) Prison staff lacked accessible, up-to-date training records for critical safety procedures (ACCT & SASH), indicating a national issue with tracking and ensuring current staff competence.
Action Taken (AI summary) Following the inquest, the Governor of HMP Liverpool issued a staff information notice promoting the use of the myLearning system for accessing training records, and a comprehensive guide on how to use the system will follow. The ACCT case management system is being updated and training packages refreshed.
Tomasz Nowasad
All Responded
2019-0445 20 Dec 2019 Manchester (City)
State Custody related deaths Suicide
Concerns summary (AI summary) There was an over-reliance on prisoners' self-declarations regarding self-harm risk, and insufficient consideration of all risk factors or the "big picture" during ACCT reviews and discharge. Risk assessment rationales were also not consistently documented.
Action Planned (AI summary) NHS England published guidelines and supporting documents for Health and Justice Clinical Reviewers in Sept 2018 and has published an amended specification for the provision of mental health services in prison. Additional resources were provided to HMP Manchester for mental health staffing. HM Prison and Probation Service are rolling out improvements to the ACCT process and are increasing the numbers of safer cells available to governors, including at HMP Manchester.
Daniel Akam
Historic (No Identified Response)
2019-0461 10 Dec 2019 South Yorkshire (East)
Mental Health related deaths State Custody related deaths Suicide
Concerns summary (AI summary) ACCT observations were missed and recorded as completed, officers did not appear to know their obligations and responsibilities, and there was inadequate ACCT training for officers.
Trevor Oakley
All Responded
2019-0495 26 Nov 2019 Hampshire
State Custody related deaths
Concerns summary (AI summary) Night staff at the prison may not be immediately aware of which prisoners are due in court the following morning, potentially overlooking increased self-harm risks among these prisoners.
Action Planned (AI summary) • The use of thromboprophylaxis to surgery has been relaunched and clarified to all pertinent staff, particularly the time period before which it should be withheld. • All speciality specific thromboprophylaxis guidelines are being reviewed.
Gary Leyland
Partially Responded
2019-0395 20 Nov 2019 Manchester (North)
Alcohol, drug and medication related deaths Suicide
Concerns summary (AI summary) The probation service failed to refer mental health concerns to medical practitioners. Supported accommodation exhibited poor documentation, unclear welfare check protocols for security staff, and inadequate risk assessment updates, without policy for GP contact.
Action Planned (AI summary) The National Probation Service (NPS) launched its Health & Social Care Strategy 2019-22, along with a Suicide Prevention Strategy Action Plan, to support collaborative and multi-agency working.
Shaun Dewey
All Responded
2019-0398 19 Nov 2019 Avon
State Custody related deaths Suicide
Concerns summary (AI summary) The elevated risk of self-harm and suicide among remand prisoners is not adequately highlighted in staff training, care practices, or national guidance documents like ACCT.
Action Planned (AI summary) HM Prison and Probation Service will review and update lists of risks and triggers as part of replacing PSI 64/2011 with a policy framework on prison safety, considering the risks posed by remand status. They will also revise the Introduction to Suicide and Self Harm Prevention training.
Neville McNair
Partially Responded
2019-0380 5 Nov 2019 East Sussex
Hospital Death (Clinical Procedures and medical management) related deaths State Custody related deaths
Concerns summary (AI summary) Prison staff lacked training in recognising and responding to opiate overdose, including Naloxone administration. Naloxone was not readily available in all risk areas, and no clear local protocol existed for its use.
Action Planned (AI summary) The Forward Trust provides substance misuse services at HMP Lewes and has a protocol for opioid overdose, with staff trained in naloxone administration. NHS England has developed a quality assurance framework to ensure quality standards are met in secure estate establishments and discussed concerns at the HMP Lewes Quality Board. HMPPS is preparing a pilot project to train prison staff in a number of prisons in the north of England to administer naloxone, and is considering the use of alternatives to intramuscular naloxone, such as nyxoid.
Alex Malcolm
Partially Responded
2019-0344 15 Oct 2019 London Inner (South)
Child Death
Concerns summary (AI summary) Insufficient Approved Premises, delays in making MARACs statutory, and difficulties recruiting probation officers due to low pay are systemic issues hindering efforts to prevent future deaths.
Action Taken (AI summary) HMPPS introduced a new pay structure in April 2018 for the National Probation Service, including a two-year pensionable pay award and a London Allowance and Market Forces Allowance to address recruitment and retention issues.
Imran Mahmood
All Responded
2019-0355 4 Sep 2019 Staffordshire South
Alcohol, drug and medication related deaths State Custody related deaths
Concerns summary (AI summary) E-cigarettes in prison are being misused as heating devices for drug preparation, highlighting a significant safety risk related to both illicit drug use and potential fires.
Action Planned (AI summary) HMPPS is considering alternative vape devices, including one using vapourless valve technology, to mitigate risks associated with e-cigarettes in prisons, but is constrained by cost and commercial availability.