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
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.
Adil  Habib
Partially Responded
2015-0380 16 Sep 2015 London Inner (North)
Community health care and emergency services related deaths State Custody related deaths
Concerns summary (AI summary) Lack of specific gate location information for prisons during 999 calls, compounded by London Ambulance Service's system not uniformly supporting alternative gate selection across all London prisons.
Action Taken (AI summary) HM Prison and Probation Service has completed a DVD covering principles of safe restraint, medical complications, and actions to take when prisoners conceal items in their mouths, which will be sent to all prison Governors by Christmas. The London Ambulance Service has augmented its computer system with additional gate information for HMP Pentonville and shared learning about confirming addresses when taking calls from prisons in a team talk.
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.
David Hallett
Historic (No Identified Response)
2015-0250 2 Jul 2015 Powys, Bridgend and Glamorgan Valleys
State Custody related deaths
Concerns summary (AI summary) HMP Rye Hill's healthcare was inadequately resourced and unprepared for its re-roll to house sex offenders, resulting in substandard patient care. This raises concerns about similar risks in future national prison re-rolls.
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.
Sharon Butcher
Partially Responded
2015-0129 31 Mar 2015 County Durham & Darlington
State Custody related deaths
Concerns summary (AI summary) There was a delay in calling for an ambulance after an emergency medical code was broadcast, and a recurring issue of lack of clarity in response to medical emergencies at HMP Frankland and HMP Durham.
Action Taken (AI summary) HMP Frankland revised local contingency plans and re-issued instructions to staff following Sharon Butcher's death to ensure that staff do not delay in calling an ambulance in all cases where there are serious concerns about an offender's health. The local protocols provide clear guidance to all staff to ensure timely, appropriate and effective response to medical emergencies.
Keith Murphy
Partially Responded
2015-0120 25 Mar 2015 Surrey
Hospital Death (Clinical Procedures and medical management) related deaths State Custody related deaths
Concerns summary (AI summary) Prison staff lack basic first aid, CPR, and defibrillator training, and healthcare provision is unavailable outside limited hours, leaving prisoners vulnerable to medical emergencies.
Action Taken (AI summary) NOMS states that first aid training is being implemented at HMP Coldingley, with custodial managers trained and monthly closedown sessions used for wider staff training. They also state that a recent Health Needs Assessment confirmed existing healthcare arrangements meet the needs of the prison population.
Stuart Baumber
Historic (No Identified Response)
2015-0116 24 Mar 2015 Peterborough
State Custody related deaths Suicide
Concerns summary (AI summary) Many prison cell doors lack anti-ligature strips due to an absent retrofit program. Furthermore, the ACCT process lacks a structured national pro forma, leading to inconsistent risk assessments and over-reliance on current prisoner demeanour.
Jason Lawson
Historic (No Identified Response)
2015-0006 9 Jan 2015 Rutland & North Leicestershire
Hospital Death (Clinical Procedures and medical management) related deaths State Custody related deaths
Concerns summary (AI summary) Welfare checks failed to identify a deceased prisoner. Prison healthcare lacked a computer-driven system to track missed and lapsed prescriptions, and there was no policy for constant medical supervision for high-risk prisoners.
John Stabler
Historic (No Identified Response)
2014-0552 18 Dec 2014 Central Lincolnshire
State Custody related deaths
Concerns summary (AI summary) The Prisoner Escort Record requires review and redesign. Furthermore, medical records systems need to be consistently available in reception and care areas within prisons.
Connor Smith
Partially Responded
2014-0540 17 Dec 2014 Liverpool
State Custody related deaths
Concerns summary (AI summary) An error in a PPO investigation listed an officer as attending a segregation review when they were absent, indicating poor investigation quality that could hinder learning from incidents.
Noted (AI summary) The PPO acknowledges a minor factual inaccuracy in their report, but argues it had no material bearing on the circumstances of the death and that they cannot take further action beyond the original recommendations to the prison. HMP Altcourse has issued a notice to all senior managers who chair Segregation Review Boards, advising them that the documentation for completion at the meeting must not have names entered in advance and that it is their responsibility to check that attendance at the meeting is correctly recorded.
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.
Barry Horrocks
Historic (No Identified Response)
2014-0492 7 Nov 2014 West Yorkshire (East)
State Custody related deaths
Concerns summary (AI summary) A disabled prisoner's essential daily living needs were unmet as the prison environment lacked adaptations and no care provider took responsibility for vital 'social services' support.
William Anderson
Historic (No Identified Response)
2014-0452 17 Oct 2014 West Yorkshire (East)
State Custody related deaths
Concerns summary (AI summary) Prison staff lacked effective vigilance over inmate gatherings involving drugs/alcohol, were insufficiently trained in breathalyser use, and failed to adequately record inmate behaviour or promptly call emergency services.
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.
Edward Devlin
Partially Responded
2014-0335 22 Jul 2014 County Durham & Darlington
State Custody related deaths
Concerns summary (AI summary) Nurses reportedly slid medication, including dangerous drugs, under locked cell doors, leading to uncertainty about patient consumption, compromised dispensing records, and risks of drug trading or stockpiling for overdose.
Action Planned (AI summary) Care UK will develop a formal policy detailing the action required by nursing staff when they are unable to administer medication to a prisoner, for example due to a threat of violence.
Matthew Purser
Historic (No Identified Response)
2014-0568 30 May 2014 Swansea & Neath Port Talbot
State Custody related deaths
Concerns summary (AI summary) A prison doctor lacked ACCT training, ACCT trigger event documentation was subjective and lacked detail for accurate assessment, and procedures for obtaining community mental health records were unclear.
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.
Andrew Hall
Partially Responded
2014-0122 12 Mar 2014 Teesside
State Custody related deaths
Concerns summary (AI summary) Inadequate communication and documentation of mental health risks, failure to administer prescribed medication, and insufficient patient observation within the prison healthcare unit were identified. Training gaps for staff in risk assessment and ACCT procedures also contributed to concerns.
Action Taken (AI summary) Cameras have been removed from cells in the healthcare centre and any prisoner assessed as requiring high levels of observation is located in a constant observation cell. A system is now in place to ensure post-closure reviews of ACCTs take place within seven days, and a local policy for an additional review after one month has been introduced.
Lee MacPherson
Historic (No Identified Response)
2014-0097 3 Mar 2014 London (West)
State Custody related deaths
Concerns summary (AI summary) Delayed police risk assessments and a lack of common understanding between escort and prison staff regarding critical handover documentation posed significant safety risks during transfers.
Lee Curran
Historic (No Identified Response)
2014-0079 25 Feb 2014 Manchester (West)
State Custody related deaths
Concerns summary (AI summary) PPO recommendations for high cholesterol and loss of consciousness protocols were not fully implemented, with NICE guidelines ignored by doctors. Additionally, prison staff lacked training in accurate medical note-taking, leading to incorrect entries.
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.
Zeeyad Hamadi
Partially Responded
2014-0014 13 Jan 2014 County Durham & Darlington
State Custody related deaths
Concerns summary (AI summary) Inadequate patient weighing and poor medical record-keeping within the prison were noted. There was limited liaison between prison and hospital staff, confusion over prisoner private healthcare policies, and delays in securing bed watch cover.
Action Planned (AI summary) The Secretary of State acknowledges the concerns and states that the National Offender Management Service (NOMS), NHS England and Public Health England (PHE) are due to meet to discuss governance arrangements for considering prisoner's requests for private treatment.
Adrian Johnson
Partially Responded
2013-0364 20 Dec 2013 London (Inner South)
State Custody related deaths
Concerns summary (AI summary) The coroner noted that initial screening did not assess for tobacco withdrawal, ACCT reviews lacked healthcare input, and there was a lack of consistency in case management, with no handover from case manager to case manager.
Action Planned (AI summary) NOMS and NHSE will give further consideration to the extent to which screening processes should identify tobacco dependence and potential withdrawal issues. ACCT refresher training will reinforce that prisoners subject to ACCT procedures should be located in segregation units only in exceptional circumstances.