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
Derrick Rose-Fowler
Historic (No Identified Response)
2016-0153 21 Apr 2016 Shropshire, Telford and Wrekin
State Custody related deaths
Concerns summary (AI summary) A prison officer lacked first aid training, potentially delaying CPR, and the bullying policy was ineffective for prisoners unwilling to name names. Critical concerns about the deceased's mental health and self-harm history were not escalated to a MASH meeting.
Steven May
Partially Responded
2016-0109 16 Mar 2016 Nottinghamshire
State Custody related deaths
Concerns summary (AI summary) Prison healthcare suffered from reception nursing staff failing to consult medical notes, lacking mental health expertise, and incomplete ACCT documents. Inadequate First Aid/CPR training and poor weekend/Bank Holiday healthcare access also posed significant risks.
Action Taken (AI summary) HMP Ranby reminded staff about comprehensive record-keeping for ACCT interviews, reinforced elements of its Local Security Strategy regarding night-time incidents, and provided access to the LSS with annual knowledge testing. The prison is taking steps to ensure compliance with PSI 29/2015 regarding training. The Trust has already addressed concerns by obtaining additional funding from NHS England for new posts at HMP Ranby to meet healthcare demands.
Richard Green
Partially Responded
2015-0456 2 Nov 2015 Cumbria
State Custody related deaths
Concerns summary (AI summary) Prison medical professionals failed to act on recorded self-harm history in SystmOne due to system usability issues, workload pressure, and a lack of clear display for critical historical information.
Action Planned (AI summary) Greater Manchester West Mental Health Foundation Trust have commissioned a review of available assessment tools for the prison setting. NHS England are re-procuring the healthcare electronic healthcare system, SystmOne, which will include sharing of risk indicators.
Rubel Ahmed
Partially Responded
2015-0308 5 Aug 2015 Lincolnshire (Central)
State Custody related deaths
Concerns summary (AI summary) Detainees were locked in rooms overnight against recommendations, staff lacked robust detention awareness and refresher training, and crucial information like removal directions was not shared.
Noted (AI summary) The Home Office acknowledges the concerns regarding the death at Morton Hall IRC. They explain the challenges of unlocking rooms overnight, the existing practices for detention awareness, and the use of electrical items, but offer no concrete action.
Paul McGuigan
All Responded
2015-0185 12 May 2015 Manchester (South)
Other related deaths
Concerns summary (AI summary) General concerns were raised across relevant agencies about risks that could lead to future deaths, requiring action.
Action Planned (AI summary) The Home Office states that the Notifiable Occupations Scheme (NOS) was withdrawn and replaced with a new police-led scheme, the Common Law Police Disclosure (CLPD) scheme, which provides greater consistency across forces in the disclosure of information. The Trust states that following the Bradley Report (2009), the MDO teams transferred into single line management and implemented operational policy and approved documentation for assessment of needs and risks. They are rolling out an electronic clinical record (PARIS) and clinical staff have adequate time to access information from case notes. GMP will train officers in understanding their responsibilities under the pressing social need test, including classroom and NCALT training. They will be entering and holding notifications on the intelligence file of offenders. The SIA offered training and guidance to all UK police forces.
Anthony Garrett
Historic (No Identified Response)
2015-0153 21 Apr 2015 Manchester (West)
Alcohol, drug and medication related deaths
Concerns summary (AI summary) Readily available and misused synthetic cannabinoids, despite warnings, are dangerous and caused a fatal cardiac event. Concerns were raised about their legal status and control.
Craig Bell
Historic (No Identified Response)
2015-0087 9 Mar 2015 Manchester City
Suicide
Concerns summary (AI summary) There was an unmet need for psychological therapies for prisoners with personality disorders, poor information sharing about self-harm risk, and a lack of senior clinician attendance at discharge reviews.
Alex Kelly
All Responded
2014-0555 28 Dec 2014 Mid Kent & Medway
State Custody related deaths
Concerns summary (AI summary) A vulnerable child was sentenced without forensic psychiatric assessment, and mental health support conflicted with disciplinary procedures, failing to adopt a holistic approach or consult outside agencies. A social worker allocation was also significantly delayed.
Action Taken (AI summary) Tower Hamlets Council details actions taken following a Serious Case Review, including maintaining social worker numbers and updating a protocol with the Youth Offending Service to clarify responsibilities when a young person receives a custodial sentence. They also highlight increased awareness among Social Work staff due to the Legal Aid, Sentencing and Punishment of Offenders Act 2012. Central and North West London NHS Trust (CNWL) describes its Health and Wellbeing Team's structure and processes, including mental health assessments and improved office space and IT access. They state that all clinical contact is recorded on Systm1, with line managers checking staff entries and annual record keeping audits to monitor documentation standards, and training provided to new team members for Systm1 use. Oxleas NHS Foundation Trust describes implementation of the CHAT tool for assessing new arrivals at HMPYOI Cookham Wood, with training and monitoring standards. They detail information governance training for staff and supervised medication dispensing procedures, including recording and reporting non-compliance. The Medway Youth Offending Service (YOT) describes actions taken in response to the coroner's concerns including ACCT training for the Resettlement Team, enhanced reviews overseen by a Governor, and submission of early release paperwork. They also detail procedures for initial planning meetings, maintaining contact, and final release meetings according to YJB National Standards. The Ministry of Justice outlines reforms in the Young People's Estate, including a standardised casework model, enhanced regimes, and changes to ACCT procedures. They detail night operating procedures and confirm that an information sharing protocol between relevant agencies at HMYOI Cookham Wood is being formulated.
Connor Smith
Partially Responded
2014-0540 17 Dec 2014 Liverpool
State Custody related deaths
Concerns summary (AI summary) An error in a PPO investigation listed an officer as attending a segregation review when they were absent, indicating poor investigation quality that could hinder learning from incidents.
Noted (AI summary) The PPO acknowledges a minor factual inaccuracy in their report, but argues it had no material bearing on the circumstances of the death and that they cannot take further action beyond the original recommendations to the prison. HMP Altcourse has issued a notice to all senior managers who chair Segregation Review Boards, advising them that the documentation for completion at the meeting must not have names entered in advance and that it is their responsibility to check that attendance at the meeting is correctly recorded.
Garry Gilbey
All Responded
2014-0533 10 Dec 2014 Portsmouth & South East Hampshire
State Custody related deaths
Concerns summary (AI summary) The prison lacked a clear policy for calling ambulances or defining medical emergencies, leading to inadequate staff training for night-time assessments and inconsistent recording of critical healthcare information.
Noted (AI summary) The Department of Health provides context regarding healthcare contracts for prisons being performance managed by NHS England's Area Teams, and refers to DH and NOMS guidance issued in 2011 regarding emergency access for ambulance services. They note that the Ministry of Justice will address prison-related issues such as training for non-medical prison staff. Since the death, Prison Service Instruction 2013/03 Emergency Response Codes has been issued, reminding staff who can call a medical emergency and providing guidance on the use of medical emergency codes. Also, the new specifications for prison healthcare services have a contractual requirement for the management of appointments and referrals, including automatic referrals to secondary care services for those who Did Not Attend (DNA).
Maria Stubbings
Historic (No Identified Response)
2014-0458 23 Oct 2014 Essex
Other related deaths
Concerns summary (AI summary) Gaps in the system allow individuals convicted of murder abroad to enter the UK without conditions or local police notification, lacking retrospective data sharing, passport warnings, or local police alerts.
Lexi Branson
Partially Responded
2014-0428 2 Oct 2014 Rutland & North Leicestershire
Other related deaths
Concerns summary (AI summary) A complete absence of national or local standards for re-homing stray dogs, assessing dog suitability, applicant suitability, or verifying kennel re-homing policies.
Noted (AI summary) The Department for Environment, Food and Rural Affairs will explore with larger dog rehoming organisations (Dogs Trust, RSPCA etc.) the possibility of sharing their rehoming checks with smaller centres and will write to these organisations to explain the coroner's recommendations. Leicester City Council acknowledges the coroner's concerns regarding stray dogs and rehoming but states they have limited power to prevent future deaths due to the disparate nature of rehoming organisations and the lack of national standards. They will convey learnings from the case to their kennel provider.
Stephen Farrar
Partially Responded
2014-0386 29 Aug 2014 Milton Keynes
State Custody related deaths
Concerns summary (AI summary) There was no formal risk assessment completed when Mr Farrar was first admitted to Woodhill Prison, despite risk factors; there is no formal risk assessment tool available in prisons.
1 response from Greater Manchester Police
Jake Hardy
Historic (No Identified Response)
2014-0305 30 Jun 2014 Manchester (West)
State Custody related deaths
Concerns summary (AI summary) Vulnerable young persons with complex needs face increased self-harm and suicide risks in Youth Offender Institutions due to staff lacking adequate training and understanding.
Redmond Johnson
Historic (No Identified Response)
2014-0279 20 Jun 2014 Suffolk
Hospital Death (Clinical Procedures and medical management) related deaths State Custody related deaths
Concerns summary (AI summary) Prison healthcare lacked robust processes for gathering detainee medical history, conducting medication reviews, documenting test results, and assessing fitness for transfer, risking inadequate care for those with complex needs.
Matthew Purser
Historic (No Identified Response)
2014-0568 30 May 2014 Swansea & Neath Port Talbot
State Custody related deaths
Concerns summary (AI summary) A prison doctor lacked ACCT training, ACCT trigger event documentation was subjective and lacked detail for accurate assessment, and procedures for obtaining community mental health records were unclear.
Hazel Polkinghorn
Historic (No Identified Response)
2014-0078 26 Feb 2014 Central Lincolnshire
Mental Health related deaths
Concerns summary (AI summary) The easy online acquisition of dangerous non-prescribed medication, like Pentobarbital, poses a significant risk of future deaths, necessitating government intervention to regulate such websites.
Lee Curran
Historic (No Identified Response)
2014-0079 25 Feb 2014 Manchester (West)
State Custody related deaths
Concerns summary (AI summary) PPO recommendations for high cholesterol and loss of consciousness protocols were not fully implemented, with NICE guidelines ignored by doctors. Additionally, prison staff lacked training in accurate medical note-taking, leading to incorrect entries.
Amy Friar
Historic (No Identified Response)
2014-0051 3 Feb 2014 Surrey
State Custody related deaths
Concerns summary (AI summary) The absence of universal emergency codes across the prison estate creates confusion for transferring staff, risking delays in emergency response.
Ishmail Kubilay
Historic (No Identified Response)
2013-0248 3 Oct 2013 Hertfordshire
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The Prison Ombudsman's clinic review identified healthcare deficiencies with national implications, but the specific recommendations are truncated in the provided text.