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 resultsPeter Campbell
All Responded
2026-0211
11 Mar 2026
Inner North London
Alcohol, drug and medication related deaths
Concerns summary (AI summary)
Drugs are rife within Pentonville prison, and there was a failure by the prison drug service to provide a meaningful interaction with the deceased between a collapse on 18 September 2024 and the fatal collapse on 3 October 2024; harm minimisation guidance was given without the recovery worker reading his medical records or having a meaningful discussion with him about his drug use.
Noted
(AI summary)
• HMPPS stated it is committed to tackling the ingress of drugs and other contraband into prisons.
• All adult male closed prisons are equipped with X-ray body scanners.
• All public sector prisons have been provided with trace detection equipment.
Mesut Olgun
All Responded
2025-0618
10 Dec 2025
Worcestershire
Suicide
Action Planned
(AI summary)
HMPPS is nearing completion of a project to convert fifty cells across thirteen establishments to ligature resistant cells, and are hopeful that further installations will be possible in 2026/27. They use the Assessment, Care in Custody, and Teamwork (ACCT) case management approach to support individuals at risk of self-harm or suicide.
Derrion Adams
All Responded
2025-0586
18 Nov 2025
Birmingham and Solihull
Alcohol, drug and medication related deaths
Concerns summary (AI summary)
Contraband and novel psychoactive substances continue to enter the prison, posing a risk to life and burdening staff during unpredictable "spikes" in incidents. Current staffing levels may be insufficient to manage these challenges.
Action Taken
(AI summary)
HMPPS is investing over £40 million in physical security enhancements across 34 prisons, including £10 million for anti-drone measures and is implementing Incentivised Substance Free Living Units in 85 prisons. They have also embedded 54 Drug Strategy Leads and 17 Group Drug and Alcohol Leads.
Scott Berry
All Responded
2026-0038
20 Oct 2025
City of Kingston Upon Hull and the County of the East Riding of Yorkshire
State Custody related deaths
Suicide
Concerns summary (AI summary)
Imprisonment for Public Protection (IPP) prisoners face profound hopelessness and mental health suffering due to indefinite detention and lack of access to parole reviews or rehabilitative programs, increasing suicide risk.
Action Taken
(AI summary)
HMPPS has implemented several measures to support IPP prisoners, including establishing a centralised shared folder for training materials, delivering refresher training to PPCS senior managers, and beginning a recall referral trial.
Angela Thompson
All Responded
2026-0027
7 Oct 2025
City of Kingston Upon Hull and the County of the East Riding of Yorkshire
Suicide
Concerns summary (AI summary)
A lack of liaison between prison and community psychiatric services for released prisoners with ongoing mental health issues, especially when geographically distant, creates risks for continuity of care.
Action Taken
(AI summary)
HMPPS has Regional Health & Justice Teams to improve integrated health services and a central Deaths Under Supervision Team to improve liaison between prison and community teams; learning from the death will be shared across HMPPS regions. HMPPS has Regional Health & Justice Teams to improve integrated health services and a central Deaths Under Supervision Team to improve liaison between prison and community teams; learning from the death will be shared across HMPPS regions.
Azroy Dawes-Clarke
All Responded
2025-0391
29 Jul 2025
Kent and Medway
State Custody related deaths
Concerns summary (AI summary)
The anti-ligature bedding failed, allowing ligature creation. Prison officers had inconsistent training on ACCT processes, first aid, and the Mental Capacity Act, leading to unclear responses during medical emergencies and conveyance.
Action Planned
(AI summary)
HMPPS is undertaking a cell design review to explore different materials that meet fire safety and anti-ligature requirements for bedding, expected to conclude at the end of 2026. To improve first-on-scene care, HMPPS have with St John Ambulance created a set of bespoke first-on-scene videos for Prison Officers and frontline staff.
Michael Pugh
All Responded
2025-0378
25 Jul 2025
Kent and Medway
State Custody related deaths
Suicide
Concerns summary (AI summary)
Inadequate ACCT process training for new prison officers led to an incomplete understanding of observation requirements, including inconsistent timing and recording for vulnerable prisoners.
Action Taken
(AI summary)
HMPPS provides a full day of training on suicide and self-harm prevention during Prison Officer Entry Level Training (POELT), including the ACCT process. HMP Swaleside will promote the Safety Learning Reference Library to new members of staff during induction and signpost it to all staff during the HMPPS annual national safety focus initiative.
Sheldon Jeans
All Responded
2025-0376
25 Jul 2025
Dorset
Alcohol, drug and medication related deaths
State Custody related deaths
Concerns summary (AI summary)
The absence of clear national and local policies on managing illicitly brewed alcohol ("hooch") and governing prisoner-held medications creates significant safety risks within the prison estate.
Noted
(AI summary)
HMP Guys Marsh has developed its Incentivised Substance Free Living (ISFL) unit, provides comprehensive staff information on illicitly brewed alcohol, and ensures in-cell medication safes are available and fit for purpose. Oxleas NHS Foundation Trust has committed to introducing regular assurance checks for all prisoners in receipt of IP medication. Oxleas NHS Foundation Trust will be developing and distributing new health promotion materials to the prison population at HMP Guys Marsh focusing on safe storage and proper disposal of medication. They have published a local In-possession Medication Compliance procedure outlining bi-monthly in-cell compliance checks. HMPPS has developed and disseminated materials focused on illicitly brewed alcohol (IBA), including the Drugs in Prison and Probation (DiPP) guide. The healthcare provider at HMP Guys Marsh, Oxleas NHS Foundation Trust, has committed to introducing regular assurance checks for all prisoners in receipt of IP medication, and in-cell lockers will be replaced if damaged. The Department acknowledges concerns about medication held in prisoners' possession, but states that national NHS policies for prisoners are the same as those used in the community. They believe existing processes, contractual monitoring, and learning from serious incidents are sufficient, and that national guidance could further complicate the issue.
Gavin Wheale
All Responded
2025-0350
10 Jul 2025
Birmingham and Solihull
Alcohol, drug and medication related deaths
State Custody related deaths
Concerns summary (AI summary)
The prison's secreted item policy inadequately addresses ingestion, and the handover from other agencies removes constant supervision, compromising the duty of care for prisoners with concealed items.
Action Planned
(AI summary)
HMP Birmingham will update its Secreted Items Policy to include guidance for staff on actions to take when a prisoner has ingested an item. They will also issue guidance to staff to ensure a fully documented risk assessment is completed for any prisoner entering the establishment under constant supervision.
Colin Lovett
All Responded
2025-0265
30 May 2025
Dorset
Alcohol, drug and medication related deaths
State Custody related deaths
Concerns summary (AI summary)
Prison staff lack essential diabetes training and understanding of critical attacks. Non-24/7 healthcare and poor awareness among staff risk delayed care and future deaths for insulin-dependent prisoners.
Disputed
(AI summary)
HMPPS does not believe it's necessary or appropriate to require all operational prison staff to undertake specific diabetes awareness training. However, following discussion with the Governor, the healthcare provider at The Verne has provided a diabetes awareness and guidance document which has been disseminated to all staff. NHS England will share the details of this case and concerns raised with all regional health and justice commissioning teams, along with links to NICE guidance and the National Diabetes Audit.
Sarah Boyle
All Responded
2025-0211
2 May 2025
Cheshire
State Custody related deaths
Suicide
Concerns summary (AI summary)
The ACCT process at HMP Styal is ineffective for preventing self-harm, lacking therapeutic mental health input. The prison holds many complex patients requiring hospital-level care, with slow transfer processes, risking future deaths.
Action Taken
(AI summary)
Following a cluster of self-inflicted deaths, the national safety team has provided support to HMP/YOI Styal, including a local safety summit and staff upskilling on suicide and self-harm awareness. The Governor and mental healthcare provider will review the process for involving mental health services in ACCT cases.
Marta Vento
All Responded
2025-0137
11 Mar 2025
Dorset
Mental Health related deaths
Other related deaths
Concerns summary (AI summary)
No formal process exists for prisons to share critical in-prison behavioural and mental health information with sentencing courts. Additionally, national guidance is lacking for ensuring continuity of care for released prisoners with mental health needs.
Action Planned
(AI summary)
NHS England required ICBs to review community mental health services by September 2024. NHS England understands that NHS Dorset would actively support the expansion of this work to support sharing of mental health care plans. The DCR Partnership is looking to have the capability to share information with others using the NRL from March 2026 onwards. The College of Policing acknowledges concerns about the lack of a bespoke risk assessment tool for violence in MOSOVO units. They will consult with the NPCC Lead for MOSOVO and relevant subject matter experts to improve guidance and direction and will liaise with Dorset Constabulary to ensure they are fully sighted on current guidance. The NPCC will request the College of Policing to review APP and training material to highlight violence risk assessment more strongly within risk management plans; they have also reiterated a request for a full review of the ARMS process. NHS Dorset supported a learning event led by NHSE regarding mental health needs, and will work with SWAST to enable access to the Dorset Care Record. They have also opened a risk on the system risk register to scrutinise the accessibility of information across system partners. HM Prison and Probation Service acknowledges concerns about sharing risk information from prison with sentencing courts and highlights the establishment of immediate release pathfinders in three prisons to develop multi-agency approaches. They will task the Safety Group in HMPPS to consider this specific area when reviewing the Prison Safety Policy Framework later in 2025-26.
Luke Barnes
All Responded
2025-0136
11 Mar 2025
Surrey
Alcohol, drug and medication related deaths
Concerns summary (AI summary)
Probation staff lack access to specialist medical reports and adequate training on neurodiverse conditions, hindering effective supervision. A loophole also prevents unactioned court sentences from being referred back for review.
Action Taken
(AI summary)
HMPPS updated its Drug Rehabilitation Requirement (DRR) Guidance in June 2025 to standardise the approach across England and Wales and ensure consistency during DRR Reviews.
Anthony Binfield, David Richards and Rolandas Karbauskas
All Responded
2025-0079
7 Feb 2025
Nottingham City and Nottinghamshire
State Custody related deaths
Suicide
Concerns summary (AI summary)
Inadequate recruitment, retention, and training of prison and healthcare staff led to severe understaffing, restricted services, and fundamental failures in prisoner welfare, supervision, and basic safety protocols.
Action Planned
(AI summary)
NHS England highlights the 'We Are Prison Nurses' campaign and nursing preceptorship to address workforce demands and notes several platforms locally to enable effective sharing of information. Findings will be tabled at a future NHS England Health and Justice Delivery Oversight Group. All Health and Justice related Reports to Prevent Future Deaths are shared and discussed at the HJDOG, and assurance is sought from regions where learning and action is identified. Serco has committed to undertaking a 'lessons learned' exercise with the MOJ and Sodexo, facilitated by the Cabinet Office, to identify aspects of the prison transition that went wrong and produce a Transitions Playbook for future use. Sodexo highlights its compliance with Early Days In Custody PSI, use of SASH forms, ACCT training, and CMS for information sharing. Post-inquests, Sodexo ringfenced key safety tasks and safer custody staff to address resourcing pressures. Nottinghamshire Healthcare NHS Foundation Trust has enhanced Executive led oversight and assurance reviews for Offender Health, mandated daily checks of electronic patient records, and requires attendance at ACCT case reviews. They have also improved handover processes and email communication. HMPPS took over management of HMP Lowdham Grange on 1 August 2024. Since then, HMPPS has increased safer custody staffing levels, established a senior management team with relevant experience, and reviewed the ACCT process. Additionally, HMPPS has disseminated existing guidance regarding document retention and will review its approach to making formal admissions at inquests.
William Bissett
All Responded
2025-0046
27 Jan 2025
Liverpool and Wirral
State Custody related deaths
Suicide
Concerns summary (AI summary)
Severe systemic failures in release planning for a vulnerable, elderly prisoner, including delayed engagement, inadequate accommodation arrangements, and insufficient emotional support, resulted in a tragic outcome.
Noted
(AI summary)
HM Inspectorate of Prisons acknowledges the report and states that the issues raised are covered by their inspection criteria. They will keep the findings on file and follow up as appropriate during the next inspection of HMP Wymott. HMPPS and NW Probation Service amended and re-issued the OMiC POM to COM Handover Guidance in March 2024. They are also undertaking a review of the quality of POM to COM handovers and commissioned a resettlement review. There is also a new safeguarding policy statement for Practitioners.
Jonathon Lawlor
All Responded
2024-0667
25 Nov 2024
Mid Kent and Medway
Alcohol, drug and medication related deaths
State Custody related deaths
Concerns summary (AI summary)
Due to severe staff shortages, keywork sessions for prisoners were drastically reduced, potentially increasing risks for those in custody, despite guidance recommending weekly meetings.
Action Planned
(AI summary)
HMP Elmley has been compiling a Key Work Delivery Strategy to address and improve the issue of key work, with the goal of ensuring that all prisoners are allocated a key worker and that specific cohorts of prisoners at risk of harm or self-harm are identified and supported by trained staff members. For 2025/6 the minimum expectation for key work delivery will rise to two key work sessions every four weeks as a minimum.
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.
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.
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.