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
Kirk Duboise
Partially Responded
2013-0329 6 Dec 2013 County Durham and Darlington
State Custody related deaths
Concerns summary (AI summary) There was a delay in summoning an ambulance and an inadequate self-harm risk assessment for a new prisoner, as essential forms were not reviewed during the reception process.
Action Taken (AI summary) Care UK has implemented protocols for summoning ambulances, disseminated to staff via a Governor's notice and staff briefings. NOMS has implemented ACCT training, with further training for healthcare staff commencing in January 2014, and refresher training on Self Harm Warning Forms is regularly undertaken.
Michael James Meyler
Partially Responded
2013-0320 2 Dec 2013 Manchester City
State Custody related deaths
Concerns summary (AI summary) Prison systems failed to adequately circulate self-harm/suicide risk information to relevant staff and attach it to ACCT documents, leading to uninformed decisions and a lack of accountability for information review.
Action Taken (AI summary) HMP Manchester reception staff now record ROSH document existence and consideration of ACCT in NOMIS. Healthcare staff scan paper documents onto SystmOne. Weekly assurance checks of NOMIS entries are conducted by Supervising Officers and Custodial Managers.
Damion Anthony Andre Martin
Historic (No Identified Response)
2013-0280 30 Oct 2013 Liverpool
State Custody related deaths
Concerns summary (AI summary) Inadequate prison risk assessment failed to identify a key suicide risk factor, first responders lacked CPR refresher training, and cell observation was compromised by restricted views and missed checks.
Jordan Buckton
Historic (No Identified Response)
2013-0187 14 Aug 2013 Dorset
State Custody related deaths
Concerns summary (AI summary) Prison staff lacked awareness of a prisoner's self-harm history due to information sharing failures. Additionally, there was inadequate follow-up after prescribing anti-depressants and a mental health course was discontinued due to staff shortages.