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.

Response Status (last 2 years, 33 reports)
Responded 15 No Response 5 Pending 1
AI Classification
Action Taken 51%
Action Planned 26%
Noted 22%
Disputed 1%
Based on 170 classified responses
PFD Reports Received by Quarter
PFD Reports
120 results
Justin Gallagher
All Responded
2019-0491 16 Aug 2019 East Sussex
State Custody related deaths
Concerns summary (AI summary) Fragmented prison healthcare failed to obtain medical history, create care plans, or assign a single clinician, missing opportunities to diagnose cancer and cancelling vital appointments due to resource shortages across multiple agencies with separate databases.
Action Planned (AI summary) The DHSC refers to the National Prison Partnership Board, which published a Principle of Equivalence in October 2019 to ensure equitable healthcare outcomes for prisoners. NHS England and NHS Improvement have taken steps to review and strengthen its quality assurance and contract performance systems. Following the death, NHS England has moved to a single provider model for healthcare in prisons to negate communication issues and ensure a single database system. Care UK was awarded the contract in October 2019, with services being mobilized for an April 2020 delivery date and oversight via contract review meetings. HMP Lewes is committed to providing resources for external escorts to medical appointments and currently makes sufficient staff available for three external hospital escorts each weekday. There is a daily meeting between prison and healthcare staff at which important information is shared.
Cherylee Shennan
Partially Responded
2019-0244 19 Jul 2019 Lancashire & Blackburn with Darwen
Other related deaths
Concerns summary (AI summary) Insufficient inter-agency communication and a lack of mandatory information sharing protocols for MAPPA Level 1 offenders with domestic abuse histories persist, despite known risks and previous reviews.
Action Taken (AI summary) Lancashire Constabulary is leading a multi-agency review of the MARAC process, testing new models for responding to cases in 'live-time', and is addressing the wider family impact of domestic abuse. They have also delivered DA and HBV/FMFGM training to probation officers and implemented 'Operation Encompass' with DA training to school staff.
Darren McGuin
Historic (No Identified Response)
2019-0221 26 Jun 2019 South Yorkshire (East)
State Custody related deaths
Concerns summary (AI summary) A significant gap in mandatory basic life support training for prison officers employed during a specific period leads to delayed CPR, with no retrospective training efforts to rectify this.
Michael Folley
Partially Responded
2019-0230 21 Jun 2019 Hampshire (Central)
State Custody related deaths
Concerns summary (AI summary) The outdated Person Escort Record (PER) system limits access to crucial past self-harm risk data. Gaps in staff training and inconsistent transfer procedures for risk information pose significant safety concerns.
Action Planned (AI summary) Hampshire Constabulary will mandate electronic self-learning packages on Prisoner Escort Records for Custody Officers and Detention Officers, review the content annually, and raise the issues in the Regulation 28 Notice at the next HM Courts and Tribunal Service working group meeting. CNWL NHS Trust details existing ACCT and SASH training, reception screening processes with standardized training being rolled out, twice-yearly care records audits, and staff supervision policies including discussion of care plans and risk assessments.
Christopher Moss
Historic (No Identified Response)
2019-0066 26 Feb 2019 Staffordshire South
State Custody related deaths Suicide
Concerns summary (AI summary) Concerns exist regarding the availability of appropriate equipment, specifically a hooligan bar, for dealing with cell door barricade incidents in prisons, potentially delaying emergency access to inmates.
Andrew Carr
Historic (No Identified Response)
2019-0038 31 Jan 2019 Birmingham and Solihull
Alcohol, drug and medication related deaths State Custody related deaths
Concerns summary (AI summary) Critical information on a prisoner's drug history was missed by the receiving prison, while drugs could be passed through the plumbing system, and contraband mobile phones exacerbated substance misuse.
Ricardo Holgate
Partially Responded
2019-0012 11 Jan 2019 Birmingham and Solihull
State Custody related deaths
Concerns summary (AI summary) Inadequate management of illicit substance misuse in prison requires further steps, including implementing CCTV on all wings and airport-style scanners at entry points.
Noted (AI summary) G4S states that HMP Birmingham is currently being managed by HMPPS and decisions regarding actions/equipment are not within their remit, but they agree with the need for CCTV and airport-style scanners and state that the governor's appointment has been extended.
Natasha Chin
Partially Responded
2019-0011 10 Jan 2019 Surrey
State Custody related deaths
Concerns summary (AI summary) Significant failures in prison medication management, including lack of information sharing with officers, unclear protocols, absent audits for critical processes, inadequate response to previous concerns, and insufficient staff training on withdrawal.
Noted (AI summary) HM Inspectorate of Prisons acknowledges the report and will place a copy in their intelligence file to inform future inspections of HMP Bronzefield. They are unable to direct the prison service to take any specific action.
Michal Netyks
Partially Responded
2018-0393 19 Dec 2018 Liverpool & Wirral
State Custody related deaths
Concerns summary (AI summary) Prison Custody Officers lack training for delivering deportation papers, and foreign national prisoners have unequal access to legal advice. Mezzanine safety at HMP Altcourse and the Home Office's conduct during proceedings were also concerns.
Action Taken (AI summary) HMP Altcourse has updated NOMIS with a record of risk assessment conversations and issued a notice to staff reminding them to use the Big Word translation service. The MoJ Estates Directorate has agreed to carry out a review of balcony design, expected to be completed in the autumn.
John Delahaye
Partially Responded
2018-0388 18 Dec 2018 Birmingham and Solihull
State Custody related deaths Suicide
Concerns summary (AI summary) National risk assessment templates are unclear on medication, and unreliable electronic records impede identifying past medical conditions. Healthcare staff are also inconsistently present or informed of crucial ACCT reviews.
Action Planned (AI summary) NHS Digital began rolling out a new mandated coding system called SNOMED CT coding from April 2018 to replace all other coding systems; and SNOMED CT has been introduced as an alternative coding system into the prison general practice electronic medical records; SystmOne since 14 January 2019.
Thomas Nicol
Partially Responded
2018-0375 30 Nov 2018 Hertfordshire
State Custody related deaths Suicide
Concerns summary (AI summary) Significant delays in transferring prisoners experiencing acute mental health crises to appropriate secure hospitals potentially endanger lives.
Action Planned (AI summary) NHS England is reviewing the Good Practice Guidance 2011 on prisoner transfers under the Mental Health Act, aiming for more clinically informed timescales. A revised document has been developed with stakeholders and is currently being prepared in readiness for public consultation anticipated in early 2019. NHS England is conducting service reviews across all adult high, medium, and low secure services, considering service capacity, security levels, gender, service types, and geographical location. It is also reviewing prison transfer and remission guidance and implementing a new service specification for integrated mental health services in prisons.
Bradley Brown
Partially Responded
2018-0374 30 Nov 2018 Manchester (North)
State Custody related deaths
Concerns summary (AI summary) Late prisoner transfers, particularly on weekends, are unsafe due to unavailable mental health assessments and limited access to healthcare records, heightening risk for vulnerable individuals.
Action Taken (AI summary) HMP Buckley Hall has instructed governors not to accept transferred prisoners on Fridays, pending healthcare changes. First night procedures have been strengthened with 72-hour monitoring and welfare checks. Healthcare staff must notify the orderly officer if prisoners miss appointments. Staff at HMP Haverigg were reminded to confirm transfers with healthcare so records are reassigned promptly.
Jacqueline Oakes
Partially Responded
2018-0419 16 Oct 2018 Birmingham and Solihull
Other related deaths
Concerns summary (AI summary) There is no system to alert other agencies when high-risk offenders are released after completing their full sentence, preventing effective risk management.
Noted (AI summary) HM Prison and Probation Service describes existing arrangements for sharing risk information with partner agencies when a high-risk offender is released, including MAPPA and MASH. Guidance on activity required at the termination of sentence is currently being written.
Thomas Lear
Historic (No Identified Response)
11 Oct 2018 Stoke-on-Trent and North Staffordshire
Suicide
Concerns summary (AI summary) A released prisoner was offered no accommodation support, and urgent suicide threats sent to his offender manager's mobile went unaddressed due to no out-of-hours coverage.
Scott Carton
Historic (No Identified Response)
2018-0287 7 Sep 2018 West Yorkshire (East)
Alcohol, drug and medication related deaths
Concerns summary (AI summary) Inadequate psychological support for prisoners with mental health and drug issues upon release, including unsuitable hostel placements without specialist input, compromises rehabilitation and increases re-offending risk.
Anthony Paine
Partially Responded
2018-0088 28 Mar 2018 Liverpool and Wirral
Mental Health related deaths State Custody related deaths
Concerns summary (AI summary) The provided text is a placeholder, stating that a brief summary of matters of concern will follow, but no specific concerns are detailed.
Action Planned (AI summary) NHS England details a service specification refresh completed in March 2018, with Spectrum benchmarking against these specifications, and revisions to approaches for secure hospital transfers, including a ten-point plan "Right Care, Right Place, Right Time", are being developed. HMPPS acknowledges concerns about healthcare provision at HMP Liverpool and highlights that responsibility for healthcare provision transferred to Spectrum Community Health CiC in partnership with Mersey Care NHS Foundation Trust on April 1, 2018, aiming for a consistent approach to care continuity.
Christopher Talbot
Historic (No Identified Response)
2017-0427 29 Nov 2017 Preston and West Lancashire
State Custody related deaths
Concerns summary (AI summary) An untrained supervising officer relied solely on shadowing, a senior officer lacked a breathing guard for resuscitation, and staff were not informed of previous unnatural death causes, reducing vigilance.
Sarah Reed
Partially Responded
2017-0238 28 Jul 2017 London (City)
Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths State Custody related deaths
Concerns summary (AI summary) Prolonged custody awaiting psychiatric reports led to significant deterioration of the deceased's mental health in a prison assessment unit, resulting in her self-inflicted death.
Action Planned (AI summary) CNWL NHS Trust has clarified report request procedures with HMPPS, ensured report requests are communicated to consultants promptly, updated care plan templates to include release planning, audited CPA meetings to improve attendance, and launched an Offender Care Transformation Board to reduce self-harm and avoid unexpected deaths. HMPPS is reviewing procedures for fitness to plead reports, developing a framework to support families with prison visits (due in 2018), implementing recommendations from the Farmer Report on family ties, and implementing a new model of offender management in custody by March 2019 to ensure external agencies are notified of a prisoner's release.
Matthew Russell
Partially Responded
2016-0430 27 Nov 2016 Surrey
State Custody related deaths Suicide
Concerns summary (AI summary) Prison healthcare exhibited failures in medication monitoring, care planning, appointment follow-up, risk flagging, and staff training for ACCT procedures and inter-professional communication.
Action Planned (AI summary) The Trust has introduced Complex Case Review Meetings at HMP Highdown, to commence in February 2017, to include GPs, Primary Care, Mental Health, Substance Misuse; Social Care, Safer Custody and Pharmacy to ensure regular communication with all healthcare providers. They will review governance structures and processes and mental health pathway to ensure continuous learning that enable us to positively contribute to reducing the Iikelihood that anyone under our care dies in custody.
Michelle Lawrence
Historic (No Identified Response)
2016-0412 8 Nov 2016 London Inner (West)
Other related deaths
Concerns summary (AI summary) Key concerns include lack of independent investigations for deaths after private custody, inadequate concealment questioning, and insufficient strip-search facilities.
Richard Walsh
All Responded
2016-0377 25 Oct 2016 London Inner (South)
State Custody related deaths Suicide
Concerns summary (AI summary) There were failures in communication between custodial and health professionals regarding the deceased's risks and needs, with crucial information being lost as he moved through different services; there was a lack of a national process for sharing mental health assessment information.
Noted (AI summary) Virgin Care has implemented a process to ensure colleagues have completed ACCT awareness training and are aware of PSI 1700 upon starting at HMP High Down, with annual refresher training. An auditing process has also been implemented for Fitness for Segregation forms, carried out by Lead Nurses. The Department of Health has brought concerns regarding AMHP training to the attention of the HCPC, which sets criteria and approves training programs. Responsibility for AMHP training is due to become the responsibility of a new regulator; Social Work England, in 2018. The Health Care Professions Council (HCPC) states that its existing criteria for AMHP training programs are appropriate and that individuals completing training have acquired the necessary skills in carrying out mental health assessments. They suggest that issues are best addressed by Local Social Services Authorities through ongoing training. Hampshire County Council and Portsmouth City Council have taken several actions, including reviewing AMHP practices, providing additional training, commissioning audits, and reviewing policies. The HCPC reviewed documentation and closed the case, taking no further action regarding the AMHP's fitness to practice.
Liam Lambert
Partially Responded
2016-0335 20 Sep 2016 Leicester City and Leicestershire South
State Custody related deaths Suicide
Concerns summary (AI summary) ACCT documents were incomplete, not properly utilized, and closed prematurely. Resourcing issues compromised officers' ability to ensure prisoner safety, especially for vulnerable young men.
Action Taken (AI summary) Following the death, a Safer Custody toolkit was introduced, and staff were reminded of ACCT document completion and prisoner supervision. Additional funding was received for security measures and partnership working. The Secretary of State announced additional prison officers to be employed, and intention to redevelop Glen Parva prison.
Stephen St Clair
Historic (No Identified Response)
2016-wp25358 12 Aug 2016 Isle of Wight
State Custody related deaths
Concerns summary (AI summary) Prison guidance for suicide risk factors is inadequate, omitting irrational behaviour as a key indicator of psychosis, which led to insufficient monitoring and care for a prisoner at risk.
Steven Trudgill
Historic (No Identified Response)
2016-0210 6 Jun 2016 Suffolk
State Custody related deaths Suicide
Concerns summary (AI summary) HM Prison Service lacked standardised treatment programs for fire setters with complex mental health issues, and a suggested therapeutic community option for the deceased was not implemented.
Adetokunbo Ajakaiye
Historic (No Identified Response)
2016-0209 27 May 2016 South Yorkshire (East)
Hospital Death (Clinical Procedures and medical management) related deaths State Custody related deaths
Concerns summary (AI summary) Prison healthcare staff lacked essential knowledge and practical experience regarding malaria and tropical diseases, posing a significant risk in an era of increased foreign travel.