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
Victoria Storey
Partially Responded
2023-0222 30 Jun 2023 Surrey
Alcohol, drug and medication related deaths Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A highly potent, illicitly traded synthetic opiate with high fatal overdose risk is not yet controlled as a Class A, Schedule 1 drug, despite official advice for its urgent inclusion.
Action Planned (AI summary) The government accepted ACMD recommendations to control synthetic opioids, including , under the Misuse of Drugs Act 1971 and intends to bring forward this legislation by the end of the year to come into force in early 2024.
Stephen Beadman
Historic (No Identified Response)
2023-0210 23 Jun 2023 West Yorkshire (Eastern)
Mental Health related deaths State Custody related deaths
Concerns summary (AI summary) A maximum-security prison with many prisoners having significant mental health issues has inadequate consultant psychiatrist resources, falling short of "equivalence of care" and risking insufficient specialist support for long-term inmates.
Girmaye Guyo
Partially Responded
2023-0195 16 Jun 2023 Manchester City
Other related deaths
Concerns summary (AI summary) There's a risk of patients being discharged under the Nearest Relative Power despite still meeting detention criteria, due to a lack of clear procedures and legal tests for clinicians to apply.
Noted (AI summary) The Department of Health and Social Care acknowledges concerns regarding the use of Nearest Relative powers under the Mental Health Act. The response notes the Responsible Clinician's powers to bar requests for discharge and states the government does not intend to amend the Nearest Relative powers.
Stuart Robinson
All Responded
2023-0161 16 May 2023 Liverpool and Wirral
Suicide
Concerns summary (AI summary) Prison ACCT reviews lacked mandatory mental health expert attendance, leading to missed opportunities to identify and support prisoners with mental health issues. This meant self-harm was not adequately addressed.
Noted (AI summary) HMPPS emphasizes that the ACCT case management approach is designed to meet the specific needs of the individual by providing multi-disciplinary support. Healthcare staff are always invited to the first case review to consider the need for any additional mental health support.
Kayleigh Burns
Historic (No Identified Response)
2023-0106Deceased 27 Mar 2023 Warwickshire
Alcohol, drug and medication related deaths Child Death
Concerns summary (AI summary) The report raises the issue of whether the present legal framework concerning Nitrous Oxide should be reviewed, in light of this death, having regard to the seemingly increasing use of Nitrous Oxide particularly by young persons.
Lewis Johnson
Partially Responded
2022-0397 12 Dec 2022 West Yorkshire (Eastern)
State Custody related deaths Suicide
Concerns summary (AI summary) HMP Wealstun lacks night-time healthcare staff, and prison officers are inadequately trained in CPR and defibrillator use for self-harm incidents, compounded by a missing policy directive for immediate resuscitation.
Action Planned (AI summary) HMPPS will update a training video for staff on emergency response, ligature use, and CPR (available Spring 2023). HMP Wealstun will resume FAW and EFAW training from April 2023, prioritizing night staff and custodial managers. HMPPS is reviewing the first aid policy and will update guidance on CPR commencement.
Michael Smith
Partially Responded
2022-0417Deceased 10 Nov 2022 County Durham and Darlington
State Custody related deaths Suicide
Concerns summary (AI summary) Insufficient staffing levels in the prison's segregation unit prevented critical medical and mental health assessments for a vulnerable prisoner. A delay in emergency response due to staffing shortages also put his life at risk.
Action Taken (AI summary) HMP Durham SACU staffing levels are above national benchmarking, overseen by a dedicated Custodial Manager. A full-time nurse is based within the SACU to provide more flexible healthcare input. HMP Durham will review its contingency plans to incorporate learning from this incident, to allow for appropriate deployment of staff should other incidents occur at the same time.
Carl Langdell
Partially Responded
2022-0331 21 Oct 2022 West Yorkshire Western
State Custody related deaths Suicide
Concerns summary (AI summary) A patient with chronic suicide risk was observed deteriorating after refusing medication. There is a systemic concern regarding items prisoners can possess in their cells overnight, and a national proposal is underway to remove identified risks.
Action Planned (AI summary) HM Prison and Probation Services conducted pilots across the prison estate, testing alternatives to the current wet shave provision, to be evaluated in Spring 2023.
Lewis Powter
Historic (No Identified Response)
2022-0223 21 Jul 2022 Cambridgeshire and Peterborough
Alcohol, drug and medication related deaths Mental Health related deaths
Concerns summary (AI summary) There is no clear policy for multi-agency information sharing meetings for complex IPP offenders, particularly when agencies lack access to shared record systems.
Jessica Laverack
All Responded
2022-0344 27 Jun 2022 East Riding and Hull
Alcohol, drug and medication related deaths Suicide
Concerns summary (AI summary) The report identifies a need for recognition of the link between domestic abuse and suicide, lack of systems to care for vulnerable individuals not meeting 'high risk' criteria, and a lack of information sharing between agencies.
Noted (AI summary) The Ministry of Justice is working with the Home Office to prioritise commitments in the Tackling Domestic Abuse Plan, including investing over £230 million in tackling domestic abuse. They have also worked to improve probation staff awareness of MARAC and published a draft Victims Bill. The Home Office acknowledges the report and states that officials will provide a full response by the stated deadline. The Home Office highlights the Domestic Abuse Act 2021, its statutory guidance published in July 2022, and the cross-Government Tackling Domestic Abuse Plan published in March. The plan includes funding, model policies, training and awareness packages. The Department of Health and Social Care is working with the Home Office on the Tackling Domestic Abuse Plan and will include measures to tackle domestic abuse in the national suicide prevention strategy. Integrated care boards are required to set out how they will address the needs of victims of abuse and NHS England is developing guidance to assist them.
Saifur Rahman
All Responded
2022-0155 26 May 2022 Birmingham and Solihull
Mental Health related deaths State Custody related deaths Suicide
Concerns summary (AI summary) Delayed emergency "code blue" calls, absence of a central cell history record, and inadequate visual risk assessments by mental health staff in the prison pose significant ongoing safety risks.
Action Taken (AI summary) BSMHFT states that it had already updated the sampling of cells under the Ligature Risk Assessment to enable greater coverage of cells from year to year, and to generate an audit trail for those cells which had been viewed in previous years. They have asked for a formal process with the prison to be placed on the agenda for the Local Delivery Board meeting. HMPPS reports that HMP Birmingham has undertaken initiatives to maintain staff awareness of medical emergency procedures, including safety talks and signage. The Governor has reviewed the local medical emergency response code protocol to ensure up to date training for all staff which is currently in progress. A central record of cell fabric history has been implemented and the prison maintenance database has been updated. A formalised process for cell ligature risk assessments is underway with the Health and Safety team, in partnership with the NHS.
Marjorie Grayson
All Responded
2022-0146 16 May 2022 South Yorkshire (West District)
Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths Other related deaths
Concerns summary (AI summary) The patient's discharge plan disregarded clear clinical advice regarding her high suicide risk and risk to family, leading to her returning home alone. There was also a failure to integrate recommendations from previous criminal justice proceedings.
Noted (AI summary) Sheffield Health & Social Care NHS Foundation Trust outlines a plan to develop a protocol for working with older adults with a forensic history, ensure thorough risk assessments when removing a service user from detention, improve communication with service users and families, ensure complex clinical decisions are multidisciplinary, and deliver online training on the Mental Health Act. The Government Legal Department, on behalf of the Probation Service, acknowledges the concerns but states it's a matter for the sentencing Judge to determine Restriction Orders. They will obtain the Court transcript of Mrs Grayson's sentencing hearing and share concerns with the Ministry of Justice colleagues in the Mental Health Caseworker team.
Michelle Jennings
Partially Responded
2023-0220 9 Feb 2022 Manchester South
Suicide
Concerns summary (AI summary) Critically long national waiting lists for mental health therapy, inconsistent application of referral/discharge policies, and a lack of proper consideration for mental health vulnerabilities during prosecutions, with no clear mechanism for sharing lessons.
Action Planned (AI summary) The Department of Health and Social Care is increasing investment in mental health services by £2.3 billion by 2023/24. They are also working to improve joined-up working across the NHS, expanding community mental health services, and growing the mental health workforce through training and recruitment.
Ian Miller
Partially Responded
2022-0001 5 Jan 2022 Gwent
State Custody related deaths Suicide Wales prevention of future deaths reports
Concerns summary (AI summary) A lack of secure medication management in prison, where prisoners controlled their own drugs, led to widespread trading of prescribed medication, posing a significant risk to prisoner safety.
Action Taken (AI summary) The prison updated its prisoner induction process in January 2022 to include information on in-possession medication, the dangers of misusing prescription drugs, and instructions to report concerns. Guidance was issued to staff in January 2022 on identifying risks, amnesty bins have been added to wings, and random medication checks have increased to 10% of the prison population.
Fishmongers’ Hall Inquests
All Responded
2021-0362 3 Nov 2021 London City
Other related deaths Police related deaths State Custody related deaths
Concerns summary (AI summary) This document is a questionnaire for the jury, intended to determine the means and circumstances by which Jack Merritt and Saskia Jones died, focusing on identifying any errors, omissions, or circumstances that may have caused or contributed to their deaths.
Noted (AI summary) CTPHQ now has CT Nominal Management specialist trained officers who will attend all future CT MAPPA (Category 4) cases and are responsible for designing and delivering a risk management plan (RMP). West Midlands Police exceeds national guidance for visits to Registered Terrorist Offenders/Pathfinders. The Learning Together Network CIC states it cannot take steps on the recommendations as it did not employ staff or run partnerships, and will be dissolved in January 2022. The Office for Students will write to all registered higher education providers in England, making them aware of the report and asking them to consider changes to their approach to risk assessment of events, programmes, and information sharing. The College of Policing acknowledges the concerns raised and states its commitment to supporting other bodies in achieving improvements in terrorist offender management. They provide broader offender management training products and guidance and will work with partners to ensure they are updated. CTPHQ now has CT Nominal Management specialist trained officers who will attend all future CT MAPPA (Category 4) cases and are responsible for designing and delivering a risk management plan (RMP). West Midlands Police exceeds national guidance for visits to Registered Terrorist Offenders/Pathfinders and now feed this into the MAPPA panel. The Secretary of State will engage with the higher education sector to encourage action to implement the recommendations and officials have spoken to the Office for Students to encourage them to take action. Officials have also engaged with HMPPS to design a new framework to define roles and responsibilities of prisons and higher education providers. The government is legislating a new power of personal search through the Police, Crime, Sentencing and Courts Bill, allowing police to stop and search terrorist offenders on license under certain circumstances. The University of Cambridge has created a new policy and guidance for staff and students working with people who have offended, and the Institute of Criminology has developed a Risk Assessment Form for all activities. The University has also stopped delivering the Learning Together programme. MoJ accepted recommendations relating to the Fishmongers' Hall attack. A new framework is being designed for Learning Together activity in prisons. Statutory guidance on MAPPA meetings will be strengthened, and the Police, Crime, Sentencing and Courts Bill includes a power for police to search terrorist offenders on licence.
Stephen Cope
Partially Responded
2021-0332 30 Sep 2021 Inner London South
Mental Health related deaths State Custody related deaths Suicide
Concerns summary (AI summary) The rapid closure of an ACCT for newly transferred prisoners, often based on minimal review, poses a risk as it fails to allow adequate time for staff to assess and understand the individual's needs.
Action Planned (AI summary) HMPPS implemented a revised version of ACCT in July 2021 that focuses on a person-centred approach, information sharing, improved case reviews and a strengthened post-closure period and shared a learning bulletin about transferring prisoners on an open ACCT which emphasises the importance of good communication and information-sharing. The Department of Health and Social Care is working with partners on the next version of the National Partnership Agreement (NPA) for Prison Healthcare, due in April 2022. NHS England is also reviewing the ACCT process in prisons and healthcare attendance, with findings anticipated in early 2022.
Emma Day
Partially Responded
2021-0263 3 Aug 2021 London Inner South
Other related deaths Police related deaths
Concerns summary (AI summary) The Gaia Centre did not record the details of protective orders, Lambeth Children’s Social Care lacked knowledge of the orders, and the Metropolitan Police Service's Merlin Report did not mention the Non-Molestation Order, highlighting a potential system failure regarding protective orders and information sharing; the Child Maintenance Service of Department of Work and Pensions also exhibited a system failure in handling reports of domestic violence.
Action Taken (AI summary) The Metropolitan Police Service now records non-molestation orders on both the Police National Computer (PNC) and Criminal Intelligence System (CRIMINT), ensuring they are identified during background checks in safeguarding incidents; also, a review of the Multi-Agency Safeguarding Hubs (MASH) was commenced in June 2021, to improve risk identification.
Joanna Daly
All Responded
2021-0245 16 Jul 2021 West Yorkshire (Eastern)
Alcohol, drug and medication related deaths State Custody related deaths
Concerns summary (AI summary) Prison staff conducting welfare checks on vulnerable first-night prisoners lack specific guidance, raising concerns about the quality and effectiveness of these critical observations.
Action Taken (AI summary) HMP New Hall introduced new processes in July 2021 to improve the quality of welfare checks, including requiring a response from residents in the First Night Centre and clarifying the purpose and requirements of the checks in a notice to staff and local operating instructions.
Serena Nicolle
Historic (No Identified Response)
2021-0212 22 Jun 2021 Surrey
State Custody related deaths
Concerns summary (AI summary) The standard prison procedure of assessing breathing through a cell hatch by observing chest movement is unreliable, leading to erroneous assessments and a risk of future deaths.
Angela Best
All Responded
2021-0194 4 Jun 2021 Inner North London
Community health care and emergency services related deaths Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths
Concerns summary (AI summary) A high-risk individual's critical discharge condition, requiring disclosure of intimate relationships, relied solely on his self-reporting despite known untruthfulness, with no independent verification mechanism.
Action Taken (AI summary) The MoJ is drafting discharge guidance for the Mental Health Casework Section (MHCS), identifying patients discharged prior to 2003 for MAPPA consideration, and revising court orders for new patients to highlight MAPPA responsibilities. They are also reviewing warrants issued in prison transfers to incorporate similar changes.
Mark Culverhouse
All Responded
2021-0189 2 Jun 2021 Milton Keynes
Mental Health related deaths State Custody related deaths Suicide
Concerns summary (AI summary) A prisoner was unlawfully detained due to a system failure where release dates were calculated after recall decisions, leading to unnecessary imprisonment, particularly over bank holidays.
Disputed (AI summary) HMPPS does not consider it possible to comply with the recommendation to calculate release dates prior to a recall decision due to complexities, staffing constraints and potential risks. They will however issue further communication to staff about using alerts on NOMIS to flag prisoners with unspent remand time.
Luke Jones
Partially Responded
2019-0409 3 Dec 2019 North Wales (East and Central)
Alcohol, drug and medication related deaths State Custody related deaths Wales prevention of future deaths reports
Concerns summary (AI summary) Concerns exist regarding the continuing accessibility and use of novel psychoactive substances (NPS) within HMP Berwyn, posing significant health risks and a high probability of future deaths.
Action Taken (AI summary) HMP Berwyn has implemented various measures to tackle psychoactive substances, including improved gate searching, changes in the supervision of domestic visits, safe detoxification on reception, and extended mandatory drug testing. A Rapiscan machine is also in place to improve detection of contraband items.
Alex Malcolm
Partially Responded
2019-0344 15 Oct 2019 London Inner (South)
Child Death
Concerns summary (AI summary) Insufficient Approved Premises, delays in making MARACs statutory, and difficulties recruiting probation officers due to low pay are systemic issues hindering efforts to prevent future deaths.
Action Taken (AI summary) HMPPS introduced a new pay structure in April 2018 for the National Probation Service, including a two-year pensionable pay award and a London Allowance and Market Forces Allowance to address recruitment and retention issues.
Philip Owen
All Responded
2019-0330 2 Oct 2019 Manchester (South)
Other related deaths
Concerns summary (AI summary) Challenges exist in safely releasing high-risk offenders after short custodial sentences, compounded by limited probation supervision and unclear communication of risks or guidance to sentencing courts.
Action Taken (AI summary) HMPPS issued Probation Instruction (PI 05/2018) setting out arrangements agreed between the Ministry of Justice and the Senior Presiding Judge for liaison between courts and probation providers.
Michael Hoolickin
All Responded
2019-0292 29 Aug 2019 Manchester (North)
Other related deaths
Concerns summary (AI summary) The coroner is reporting to prevent future serious further offence reviews following a death.
Noted (AI summary) The NPCC acknowledges the concerns and explains its role in encouraging collaboration between forces, stating that it will share the report and IOM guidance with chief constables across the country, but does not have the authority to direct action. The Probation Service acknowledges the need for learning and improvement. The Greater Manchester IOM Framework is currently subject to review and your concerns will be considered as part of this review. Where deemed necessary further guidance or clarification including templates such as draft agenda, minutes and action logs will be included. Response contains no text. Response contains no text.