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
65 results
Nicky Reilly
All Responded
2019-0014 4 Jan 2019 Manchester (North)
Mental Health related deaths State Custody related deaths
Concerns summary (AI summary) The provided text is incomplete and does not detail specific concerns regarding future deaths, primarily describing the deceased's history and transfer.
Action Taken (AI summary) Prison psychology teams can request access to patient's clinical records and have been informed how to gain access. A rewritten guidance document for staff addresses patients who are non-concordant with medication, referencing actions for staff during weekdays and weekends; it was circulated to staff in December 2018. HMPPS provides a Care and Management Plan for prisoners managed by the Managing Challenging Behaviour Strategy (MCBS). They are rolling out 'Working with Challenging Behaviour' training, have developed a toolkit to help staff meet the needs of those with Learning Disabilities and Challenges (LDC), and are opening a dedicated unit for prisoners with autism at HMP Wakefield.
Nicola Lawrence
All Responded
2018-0318 23 Oct 2018 West Yorkshire (East)
State Custody related deaths
Concerns summary (AI summary) A critical concern was that some prison staff lacked essential cardiopulmonary resuscitation (CPR) training, both initial and refresher, jeopardizing emergency response.
Noted (AI summary) HM Prison & Probation Service acknowledges concerns about CPR training at HMP New Hall. They state that the governor has reviewed staff training and considers the current number of trained staff sufficient based on a first aid risk assessment, referring to PSI 29/2015.
Dean Barrell
All Responded
11 Oct 2018 East Sussex
State Custody related deaths
Concerns summary (AI summary) A seven-day delay in communicating a vulnerable prisoner's actual release date to HMP Lewes contributed to his suicide, highlighting unacceptable communication delays for vulnerable individuals.
1 response from Dean BARRELL
Sam Molyneux
All Responded
2017-0340 13 Sep 2017 Liverpool & Wirral
State Custody related deaths
Concerns summary (AI summary) Old prison wings lacking anti-barricade doors delayed emergency access, and a prisoner with documented self-harm threats was not placed on an appropriate monitoring plan (ACCT).
Action Planned (AI summary) HM Prison & Probation Service will revise the ACCT form and PSI 64/2011 Safer Custody policy to direct staff to consider emergency access, including the presence of an anti-barricade door, when locating prisoners on ACCT. This will also be included in ACCT case manager training.
Sean Plumstead
All Responded
2017-0316 9 Aug 2017 Hampshire (Central)
State Custody related deaths
Concerns summary (AI summary) Winchester Prison has inadequate systems for storing electronic material and creating transcripts, leading to missing crucial evidence. This recurring issue raises a risk of future deaths due to poor record-keeping.
Action Planned (AI summary) HMP Winchester has taken on a temporary staff member to transcribe telephone calls, implemented a new protocol for information gathering, transcribed interview discs, and ordered a secure storage facility for documentation regarding any death in custody. The Head of Business Assurance is reviewing accounting systems and storage of internal investigation material. Carillion has contacted HMPPS and proposed a formal instruction for staff to undergo SASH training, is ready to issue a notice to site managers to make staff available, and suggested that HMPPS maintain a training record for Carillion staff. HMPPS has confirmed that all Carillion prisoner facing staff should be required to undergo training. The prison has issued notices to staff regarding emergency call bell response times and to prisoners about the misuse of call bells. The prison is also checking ECB response times daily and bidding for funding to upgrade the ECB system; nationally, a learning bulletin will be issued to staff on ECB importance and abuse in early 2018.
Edwin O’Donnell
All Responded
2017-0258 13 Jul 2017 Liverpool & Wirral
State Custody related deaths
Concerns summary (AI summary) Prison health reception screening failed due to lack of access to critical mental wellbeing documents and significant delays in follow-up screening. Additionally, probation staff lacked adequate ACCT training.
Action Taken (AI summary) The Senior Officer in reception now provides a copy of the Person Escort Record (PER) to healthcare staff and reception staff have been made aware of this process. The individual concerned has been reminded of the circumstances under which it is appropriate to open an ACCT, and suicide and self-harm training is being rolled out to all staff.
Roy Hoey
All Responded
2016-0360 13 Oct 2016 Liverpool and Wirral
State Custody related deaths
Concerns summary (AI summary) Concerns arose from staff confusion regarding the interpretation and application of safer custody guidance, specifically when to open an ACCT plan, requiring clarification on mandatory assessment before initiation.
Action Planned (AI summary) NOMS acknowledges potential confusion regarding ACCT guidance and will resolve this in the revision of PSI 64/2011, due for completion by the end of April 2017; the revised version will be easier for staff to read and understand.
Kevin Forster
All Responded
2015-0453 28 Oct 2015 County Durham and Darlington
Alcohol, drug and medication related deaths State Custody related deaths
Concerns summary (AI summary) HMP Durham had a serious drug problem, but staff lacked awareness and training on overdose policies, leading to complacent responses, inadequate treatment plans, and delayed emergency calls for prisoners under the influence.
Action Taken (AI summary) Healthcare staff have been reminded of the importance of full and contemporaneous notes, and training has been provided on substance misuse; clinical guidelines are being developed for substance misuse issues, including a treatment plan template on SystmOne. Posters are planned for discipline staff areas, and training will be repeated to prison officers on emergency code allocation. All staff have signed to confirm their understanding of the Emergency Code Protocol, and managers have verified their awareness. Pocket-sized cards explaining the protocol have been issued, and the protocol is displayed in prominent areas and explained to new staff during onboarding; the protocol has been an agenda item at team meetings, and the issue has been addressed by the Deputy Governor and the Governor.
Luke Myers
All Responded
2015-0292 20 Jul 2015 Liverpool
State Custody related deaths
Concerns summary (AI summary) HMP Liverpool miscalculated the deceased's sentence, which was a likely factor in his death. Additionally, prison discipline staff lacked current first aid training, raising concerns for lone working officers.
Action Taken (AI summary) HMP Liverpool has reviewed sentence calculations and found no other miscalculated sentences. First aid training is being provided to all Custodial Managers who carry out orderly officer duties, and Operational Support Grade staff will also be trained.
Paul McGuigan
All Responded
2015-0185 12 May 2015 Manchester (South)
Other related deaths
Concerns summary (AI summary) General concerns were raised across relevant agencies about risks that could lead to future deaths, requiring action.
Action Planned (AI summary) The Home Office states that the Notifiable Occupations Scheme (NOS) was withdrawn and replaced with a new police-led scheme, the Common Law Police Disclosure (CLPD) scheme, which provides greater consistency across forces in the disclosure of information. The Trust states that following the Bradley Report (2009), the MDO teams transferred into single line management and implemented operational policy and approved documentation for assessment of needs and risks. They are rolling out an electronic clinical record (PARIS) and clinical staff have adequate time to access information from case notes. GMP will train officers in understanding their responsibilities under the pressing social need test, including classroom and NCALT training. They will be entering and holding notifications on the intelligence file of offenders. The SIA offered training and guidance to all UK police forces.
Mark Groombridge
All Responded
2015-0142 17 Apr 2015 Staffordshire (South)
Other related deaths
Concerns summary (AI summary) There was no direct communication between the local offender manager and the clinician responsible for the patient's care before the recall paperwork was issued, and there was confusion about the recall process among probation staff.
Action Planned (AI summary) While the Director of Probation believes existing guidance on offender recall is clear, Deputy Directors will ensure probation staff are reminded of procedures by 31 August. The Public Protection Casework Section (PPCS) will issue a Senior Leaders Bulletin covering recall actions and will organise Recall Practitioner Forums in each National Probation Service (NPS) division at the end of the year.
Geraldine Kilborn
All Responded
2014-0532 10 Dec 2014 County Durham & Darlington
State Custody related deaths
Concerns summary (AI summary) There was a clear breakdown in mental health information sharing within ACCT reviews, where mental health input was not sufficiently weighted and members often relied on potentially misleading face-to-face assessments without reviewing documentation.
Action Planned (AI summary) An amended arrangement has been put in place to facilitate the presence of a member of the mental health team at ACCT reviews that take place at the weekend. Effective mental health input is now ensured in all cases in which a prisoner has mental health issues. Briefing sessions have been introduced to facilitate the sharing of information between prison staff and the mental health team. From April 2015 the health service delivery model will change from a Prime Provider model to a 7 Lot commissioning model. Daily reviews will be undertaken by a member of the mental health team, as on any patient allocated for, Healthcare with mental health issues: In addition all complex ACCT cases will be discussed at morning handover to increase staff awareness. A registered nurse with previous knowledge of the patient will be in attendance at an ACCT review. TEWV has already made changes to the availability of Mental Health Team staff over the weekend. Staff are on duty between 9.30 am - 1230pm Saturday and Sunday, with a priority role to ensure that the relevant ACCT reviews are attended and that those women in crisis are offered support. Staff were reminded to read all the relevant information in the ACCT document and on System One notes.
Sean Brock
All Responded
2014-0381 8 Aug 2014 Milton Keynes
State Custody related deaths
Concerns summary (AI summary) A significant reduction in prison officer numbers at HMP Woodhill directly compromises prisoner safety and poses a risk to lives.
Noted (AI summary) HMP Woodhill staffing levels have been benchmarked and agreed upon, with ongoing local and national recruitment efforts to address vacancies. Information sharing between prison staff and contractors is a priority.
Kevin Scarlett
All Responded
2014-0174 15 Apr 2014 Milton Keynes
State Custody related deaths
Concerns summary (AI summary) The prison service and healthcare failed to assess the deceased's suicide risk, as staff lacked access to proper risk assessment tools or protocols.
Action Taken (AI summary) HMP Woodhill reviewed the local ACCT process in December 2013, revised the case review process, and issued guidance to staff. A governor grade is appointed to manage the case of each prisoner subject to the ACCT process who is assessed as having complex needs.
Ryan Clark
All Responded
2014-0057 3 Feb 2014 West Yorkshire (East)
Other related deaths
Concerns summary (AI summary) Prison procedures like the Personal Officer Scheme, ACCT checks, and roll call were not properly implemented. Additionally, prison officers lacked sufficient first aid and CPR training.
Action Planned (AI summary) HMP and YOI Wetherby implemented a revised personal officer scheme in October 2013 to ensure greater continuity in the allocation of staff to young people, including a 'relief' arrangement and key points for officers' roles. Leeds City Council has agreed on a procedure between Children's Social Work Service and Youth Offending Service to share all relevant information about a young person going into custody with the Young Offender Institution staff within 24 hours of arrival.