Ministry of Justice

PFD Addressee
Reports: 120 Earliest: Oct 2013 Latest: 8 Apr 2026

45% 2-year response rate (below 83% average). 51% of classified responses show concrete action taken.

PFD Reports
120 results
Barrie Forster
All Responded
2024-0603 5 Nov 2024 Cornwall and the Isles of Scilly
Other related deaths
Concerns summary (AI summary) A severe shortage of suitable accommodation for released prisoners, including Approved Premises and local authority housing, leads to homelessness or unsuitable placements, increasing supervision difficulties.
Action Planned (AI summary) MoJ and MHCLG are working on a long-term strategy to end homelessness, including for prison leavers, with publication expected next year. Funding for homelessness services is increasing, and MHCLG will promote a partnership approach to statutory referrals and information sharing.
Wayne Bayley
All Responded
2024-0605 31 Oct 2024 Inner North London
State Custody related deaths
Concerns summary (AI summary) National replication of healthcare improvements, especially understanding sickle cell crisis risks and prisoner care, has not occurred across all UK prisons, posing a risk that lessons learned are not widely applied.
Noted (AI summary) NHS England is undertaking training and upskilling of healthcare and prison staff in the London region. They are also reviewing service specifications and will use learning from the case to strengthen requirements around assessment and management of long-term conditions. HMPPS acknowledges the concerns and refers to ongoing work led by NHS England to improve awareness of sickle cell disease and other long-term conditions, stating their commitment to working collaboratively with healthcare providers.
Stephen Sleaford
Partially Responded CC
2024-0550 14 Oct 2024 Leicester City and South Leicestershire
State Custody related deaths
Concerns summary (AI summary) There's a severe lack of first aid and CPR training for prison officers, including new recruits, creating critical response gaps. Routinely obscured cell observation panels and unclear guidance on emergency cell entry further compromise prisoner safety.
Action Taken (AI summary) HMPPS re-issued the First Aid Policy Framework in August 2023, re-issued a notice to staff in October 2024 reminding them of the importance of challenging prisoners who block their observation panels, and issued a new film, ‘Responding to emergency situations’.
Ian Deavall
Partially Responded
2024-0485 9 Sep 2024 Greater Manchester West
State Custody related deaths
Concerns summary (AI summary) A significant risk exists in HMP Forest Bank due to emergency cell bells being easily deactivated by other prisoners, potentially delaying critical medical responses.
Action Taken (AI summary) HMP Forest Bank has split the induction across two wings, housing vulnerable prisoners and non-vulnerable prisoners separately, eliminating the risk of cell call bells being cancelled by other prisoners. Plans for future investment with regards to the cell call system will be determined by the competitions process and award of future contracts.
Sean Davies
No Identified Response CC
2024-0460 8 Aug 2024 Mid Kent and Medway
Suicide
Concerns summary (AI summary) Inadequate risk formulation for IPP prisoners and failures by prison officers to conduct welfare checks according to guidance. Furthermore, some operational support staff lacked proper training or adhered to it.
Matthew Braben
No Identified Response CC
2024-0423 1 Aug 2024 West London
State Custody related deaths Suicide
Concerns summary (AI summary) Inadequate recognition of childbirth as a mental health risk factor, poor ACCT process and staff training, and prolonged cell confinement due to gym instructor shortages significantly harmed prisoner mental health.
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.
Yasmin Adams
All Responded
2024-0330 20 Jun 2024 Derby and Derbyshire
State Custody related deaths
Concerns summary (AI summary) Prison ACCT observations allowed overly long gaps, and fixed shower rails presented ligature risks. Staff lacked training on personality disorder/learning disability, and vulnerable prisoners were held in unsuitable cells.
Noted (AI summary) HMPPS acknowledges concerns about ACCT observations, shower rails, personality disorder training, and cellular confinement, explaining existing policies and planned improvements without committing to specific new actions.
Christopher MacGillivray
Historic (No Identified Response) CC
2024-0297 29 May 2024 Newcastle and North Tyneside
Alcohol, drug and medication related deaths Suicide
Concerns summary (AI summary) Prison policies lack mandatory procedures for communicating self-harm risk for remand prisoners on unplanned releases, leaving a critical gap in managing safety for vulnerable individuals released at short notice.
Hayley Cowan
Partially Responded CC
2024-0291 29 May 2024 Manchester North
Mental Health related deaths
Concerns summary (AI summary) There is a critical lack of consistent and clear national guidance for Mental Health Trusts on defining and implementing Section 17 leave for detained patients, leading to inconsistent policies and practical instructions for staff.
Action Taken (AI summary) Greater Manchester Mental Health NHS Foundation Trust's adult forensic service had an escorting patient policy in place, however this has been updated; the adult forensic service had an induction programme in place for training staff on escorts, however this has been revised to be a standalone training resource; the service has also facilitated a quality improvement initiative to refresh the pre-leave assessment.
Elizabeth McCann
All Responded
2024-0288 29 May 2024 Manchester South
Other related deaths
Concerns summary (AI summary) High probation caseloads, inadequate supervision for new staff, and limited information sharing protocols between agencies, coupled with severe, long-standing understaffing in police Sexual Offender Management Units, compromised effective offender management.
Noted (AI summary) The College has a new Standard Operating Procedure for all referrals received from external agencies. The Trust is developing an organisational approach to investigations as part of the nationally mandated work to implement the Patient Safety Incident Response Framework and is commissioning a training programme that will provide attendees with enhanced skills in reviewing and learning from patient safety incidents; the Executive Director of Quality, Nursing and Health Professionals has also introduced new governance processes. The Trust's safeguarding leads have supported College leads in developing a more robust safeguarding policy for enrolees, provided additional learning sessions to college staff and volunteers, and have a rolling programme of support in place; Additionally, the Executive Director of Quality, Nursing and Health Professionals has introduced new governance processes including a Central Safety Summit with an approved scope and purpose agreed at Board level with reporting into the Trust’s Quality Committee for continuous oversight at a Non-Executive Director level. The Home Office is working with police forces to ensure improvements in effectiveness and efficiency of the system to manage sex offenders and prevent them from committing further harm, and is working with the National Police Chiefs’ Council’s Violence and Public Protection and Violence Against Women and Girls portfolios. The VKPP engages with forces and key partners to identify promising practice and share knowledge to shape future responses to serious crime that exploits vulnerability. HMPPS is developing a new Continuing Professional Development risk learning product to be piloted towards the end of this year before being launched from February 2025, and has identified SEEDS2 as a strategic learning priority for 2024-2025 with Probation Officers required to complete the learning by September 2025 as part of their Continuing Professional Development requirement. No actions or plans described.
Christine McDonald
Partially Responded CC
2024-0278 21 May 2024 Cheshire
Suicide
Concerns summary (AI summary) Failure to use emergency response codes left first responders unprepared for critical situations, compounded by training difficulties in simulating unexpected emergency scenarios.
Action Taken (AI summary) HMPPS launched a video in January 2024 demonstrating how staff should respond to a medical emergency, including the use of Code Blue and Code Red communications, which has been delivered to all new officers via foundation training. HMP Styal are committed to showing the video to all current operational members of staff by November 2024.
James Furlong, Joseph Ritchie-Bennett and David Wails
All Responded
2024-0276 20 May 2024 Central Criminal Court
Other related deaths
Concerns summary (AI summary) No specific concerns were detailed in the provided text, only a general statement about "The Failures that Contributed to the Deaths".
Noted (AI summary) NHS England acknowledges concerns about secondary healthcare in prisons, particularly staffing shortages, but focuses its response on NHS England's remit. They have engaged regional colleagues and will consider responses from other Trusts, while also highlighting national work on PFD reports. Berkshire Healthcare has continued developing the One Team model, implemented monthly audits of Community Mental Health Team caseloads, and conducted various training programs (suicide awareness, trauma-informed care). They have also improved VCSE engagement and reinforced MAPPA escalation processes. Oxford Health NHS Foundation Trust will consider introducing guidance for psychological therapy staff about recording when an individual declines treatment in prison, to include guidance that declined offers of treatment are always considered in caseload management supervision. Thames Valley Police details actions taken by both the force and Counter Terrorism Policing South-East, including improvements to intelligence dissemination, Prevent training, MAPPA procedures, and Operation Plato. A multi-agency exercise was conducted to test the effectiveness of the Operation Plato plan. Midlands Partnership NHS Foundation Trust has refreshed the psychology pathway and updated referral criteria, and is standardising practice in regard to psychological care pathways. They have also developed a pilot of the Mental Health & Wellbeing Practitioner role and provide ongoing training for staff. The Ministry of Justice outlines changes to probation and prison procedures, including enhanced risk assessment tools, improved information sharing through MAPPA, and updated training for staff. These changes aim to better manage individuals who pose a terrorism risk. The Home Office describes ongoing improvements to the Prevent programme including reviews, case assurance, and annual statistics. They are implementing improved information sharing practices and conducting assurance reviews of training and processes related to discontinuing impending prosecutions.
Luke Pearce
Partially Responded
2024-0270 16 May 2024 Staffordshire and Stoke on Trent
Suicide
Concerns summary (AI summary) Staff lack timely training and guidance on appropriate cell entry during medical emergencies and correct use of Code Blue/Red communications, risking delayed or improper responses.
Action Taken (AI summary) A new national video on medical emergency procedures, including entering cells and using emergency codes, was launched in January 2024 and made available to all HMPPS staff. The Governor of HMP/YOI Swinfen Hall has been showing the video to existing staff as part of Safety Critical training with the goal of completion by March 2025.
Paul Day
All Responded
2024-0274 10 May 2024 Derby and Derbyshire
Alcohol, drug and medication related deaths State Custody related deaths
Concerns summary (AI summary) Prison CPR guidance, particularly the inclusion of rigor mortis as an exclusion, is inappropriate for untrained staff in non-24-hour healthcare facilities, risking missed opportunities for life-saving resuscitation.
Action Planned (AI summary) HM Prison and Probation Service acknowledges concerns about CPR guidance and will review and revise the guidance regarding rigor mortis as a sign of death, following advice from the Resuscitation Council UK.
Alan Davies
All Responded
2024-0160 21 Mar 2024 South Wales Central
State Custody related deaths Wales prevention of future deaths reports
Concerns summary (AI summary) There was limited communication between Caswell Clinic and HMP Cardiff regarding the patient's condition; discharge information was not provided in a clear format, and the patient was transferred without being accompanied by a member of Caswell Clinic staff.
Action Taken (AI summary) The Department of Health and Social Care outlines national measures to improve urgent and emergency care, including funding increases for ambulance trusts, hospital beds, and discharge support. It also notes improved Category 2 ambulance response times nationally and in the NWAS region, and decreased patient handover times. HMPPS has received assurance from the Governing Governor at HMP Cardiff that all staff are aware of emergency medical codes via the radio system. The Governor is also committed to encouraging staff to raise concerns about an individual's management and will discuss with the Head of Healthcare how healthcare staff can be empowered to do so. Swansea Bay University Health Board has developed a Standard Operating Procedure for transferring individuals with mental/physical health needs into their care. They have also improved the service level agreement with a local GP practice, recruited additional GPs and implemented changes to the night shift pattern to alleviate staff workload.
Matthew Price
All Responded
2024-0102 22 Feb 2024 West Yorkshire (Eastern)
State Custody related deaths Suicide
Concerns summary (AI summary) Concerns are raised about the welfare of individuals subject to IPP sentences, highlighting anxiety over recall and the belief that seeking mental health support could hinder their discharge process.
Action Taken (AI summary) HMPPS provides Introductory Suicide Prevention Training for probation staff and has developed a 7-minute briefing on suicide prevention. They are also working closely with other government departments to ensure prison leavers can access healthcare and support, and are drawing together a holistic staff IPP guide.
Sobhia Khan
All Responded
2024-0088 16 Feb 2024 Derby and Derbyshire
Other related deaths
Concerns summary (AI summary) Inadequate Ministry of Justice scrutiny of discharge reports and a lack of forensic pathways for high-risk Mental Health Act patients, compounded by insufficient police powers to intervene for public safety.
Noted (AI summary) Derby City Council has made changes to manage mentally disordered offenders, including working alongside the Forensic Community Mental Health Team and finalizing a Memorandum of Understanding to employ a Senior Social Work Practitioner. They also introduced regular training for social supervisors and a rolling programme of Unconscious Bias training. Derbyshire Healthcare NHS Foundation Trust has invested in a Forensic Community Mental Health Team, which has undertaken shared cultural awareness training with the police and probation. The Trust has adopted Systm1 as its electronic patient record system and conducts ongoing record keeping audits. Derbyshire Constabulary has strengthened the protection offered to vulnerable people via civil orders and Stalking Protection Orders. The force has a comprehensive programme of activity to raise standards and improve record keeping, and all officers and staff now receive training on cultural aspects. Cygnet has reviewed the PFD action plan at Clinical Governance meetings and shared it with relevant teams; all staff complete a report writing and record keeping Skill workbook, and Cygnet audits on triangulation of records are completed 3 monthly. Response is a placeholder document.
Mark Pryor
Partially Responded CC
2024-0063 6 Feb 2024 Derby and Derbyshire
State Custody related deaths
Concerns summary (AI summary) Healthcare Professionals in police custody suites may lack sufficient and adequate training to practice effectively or safely, potentially compromising clinical assessment and treatment for detainees.
Action Planned (AI summary) CRG Medical Services will extend their foundation training course for new recruits from two to five days, starting in financial year 2024/25. Clinical Leads and senior HCPs will attend a training course on presentation skills, and new recruits will work five shifts under intensive supervision of a senior HCP. The FFLM has highlighted the coroner's report to its members, re-confirmed the importance of education and training, and is exploring additional training in the management and care of detainees dependent on drugs or alcohol. They have also published recommendations and guidance on their website to support education and training in Forensic Medicine.
Samuel Jones
All Responded
2023-0499 5 Dec 2023 Dorset
State Custody related deaths
Concerns summary (AI summary) Prison and healthcare record systems failed to flag critical "trigger dates" for vulnerable prisoners. Staffing shortages prevented thorough record review, and system limitations meant crucial information was frequently overlooked.
Noted (AI summary) HMPPS will revisit recording key dates as it continues to develop the Digital Prison Services (DPS), and it anticipates the ability to search for key words will be available by 2025. It will also issue a Senior Leaders Bulletin on the importance of recognising key dates and encouraging the use of local databases. NHS England describes the Health and Justice Information Service (HJIS) and options for flagging key dates, and refers to NICE guidance on managing medicines. It states that responsibility for cell searches lies with HMPPS. The Ministry of Justice acknowledges the concerns raised and states that HM Prison and Probation Service (HMPPS) will respond to the operational issues; the Minister endorses the HMPPS response.
Terri Harris, John-Paul Bennett, Lacey Bennett and Connie Gent
Partially Responded
2023-0467 7 Nov 2023 Derby and Derbyshire
Other related deaths
Concerns summary (AI summary) Probation Service offender records lacked clear, prominent recording of critical risk information, leading to unread vital details and insufficient domestic abuse and child safeguarding checks. Systemic issues contributed to ongoing risks.
Action Taken (AI summary) Phoenix Futures will send a Probation Feedback Form within 48 hours of attended appointments and 24 hours of failed appointments and will conduct monthly audits of compliance. HMPPS is updating guidance on Drug Rehabilitation Requirements (DRR) and Alcohol Treatment Requirements (ATR), and has launched new joint working arrangements detailing the roles and responsibilities of both the Probation Service (PS) and Treatment Providers (TPs) in the East Midlands in Derby and Derbyshire. Capita reinforced safeguarding requirements, created a mandatory training module, and implemented a 'clear chain notification' (CCN) for reporting potential risk of harm. The contract with MOJ ends 30 April 2024 and is being taken over by Serco.
Jonathan McCarthy
Partially Responded
2023-0402 24 Oct 2023 Northampton
State Custody related deaths
Concerns summary (AI summary) Prisons failed to verify and manage critical pre-existing community hospital appointments for prisoners, and lacked fitness-to-transfer assessments, impacting medical care and safety during transfers.
Action Taken (AI summary) Practice Plus Group implemented a new transfer process in November 2023 to ensure the safe transfer of patients, including a transfer document that includes future external appointments. "Medical Hold" will be utilised to ensure that patients booked for urgent or specialised treatments/appointments are not transferred until the appointment has taken place.
Manoel Santos
Partially Responded
2023-0361 3 Oct 2023 Inner South London
State Custody related deaths Suicide
Concerns summary (AI summary) Delays in notifying foreign national offenders of immigration detention and inadequate access to legal advice are compounded by poor inter-agency communication and a lack of specialist prison staff for immigration matters.
Action Taken (AI summary) The Home Office has implemented new commissioning and handling processes and established a Strategic Improvement Operations team within FNORC to log, review, and track recommendations from internal and external investigations, ensuring risks are managed consistently. They also use a specific form called ‘Request for Risk Information’ to request an OASys assessment. These are now centrally administered by the FNO coordination hub to ensure that there is a central referral point for the Home Office. The request is then sent directly to the relevant practitioner to action, or the team if the matter is not yet allocated. An escalation process that highlights responses that have not been received within 20 days has also been introduced. Practice Plus Group has implemented weekly and fortnightly meetings between healthcare management and prison governors to improve communication between agencies. They have also clarified the established process regarding concerns for a prisoner's safety, where officers should inform a member of the healthcare team if they are presence. HMPPS has re-issued a notice to staff at HMP Belmarsh clarifying procedures for unlocking cell doors during the night state, emphasizing preservation of life takes precedence. Additionally, learning from probation-involved inquests will be disseminated across the probation service, and included as part of the Offender Management in Custody (OMiC) model of working.
Kristopher Tilbury
Historic (No Identified Response)
2023-0331Deceased 8 Sep 2023 Hertfordshire
Alcohol, drug and medication related deaths State Custody related deaths
Concerns summary (AI summary) HMP The Mount failed to control illicit drug supply, including psychoactive substances, leading to high availability even on a 'Wellbeing Wing' and multiple subsequent drug-related deaths.
Stephen Weatherley
All Responded
2023-0269 20 Jul 2023 Inner South London
Alcohol, drug and medication related deaths State Custody related deaths
Concerns summary (AI summary) Significant issues with data recording and retention in HMP Thameside led to lost critical documents and incomplete records, alongside the absence of a written drug swallow policy.
Noted (AI summary) HM Inspectorate of Prisons acknowledges receipt of the report but states its remit is limited to the inspection process, referring to published inspection reports and stating the information will inform future risk assessments at HMP Thameside. HM Inspectorate of Prisons acknowledges receipt of the report but states its remit is limited to the inspection process, referring to published inspection reports and stating the information will inform future risk assessments at HMP Thameside. Serco (HMP Thameside) details actions taken, including the introduction of MS Teams folders for data retention, enhanced security strategies with trained analysts, and the implementation of a bodyscanner, with learnings from the inquest shared with senior management. They will also share learnings of the inquest with the senior management team, with advice that where there is a suspected 'swallow' and absence of a positive bodyscanner result, they should re-locate to healthcare. HM Prison and Probation Service acknowledges the concerns regarding record keeping and data retention at HMP Thameside, confirms receipt of the prison director's response, and outlines the contract delivery indicators and monitoring processes in place.