State Custody related deaths

Concerns 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.

Concerns 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.

Concerns summary A ligature point in a healthcare wing cell, not designed as a "safer cell," was used by the deceased and remains an unaddressed risk without plans for remedy.

Concerns summary Prison clinical staff lack mandatory training for the critical NOMIS system, preventing them from accessing vital prisoner information and compromising safety.

Concerns 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.

Concerns summary Poor hygiene in non-clinical prison healthcare areas creates infection risks. A systemic failure allowed a senior house officer to miss a critical post-surgery VTE risk assessment, indicating a broader protocol adherence issue.

Concerns summary Prison officers lacked essential first-aid and resuscitation training, and welfare checks during cell unlocks were routinely neglected despite clear instructions, indicating systemic safety failures.

Concerns summary Prison discipline and healthcare staff exhibited confirmation bias regarding drug use, leading to inadequate investigation, poor record-keeping, insufficient training on new psychoactive substances, and a lack of clear escalation protocols for medical emergencies.

Concerns summary The prison service demonstrated a reduced capacity for self-harm risk assessment, with failures in re-evaluating risk after significant patient changes, providing adequate pain management, and informing new wings of altered risk profiles.

Concerns summary Systemic failures involved prison officers failing to conduct and falsely recording ACCT observations for vulnerable prisoners. Inadequate ACCT training meant officers lacked understanding of their crucial responsibilities.

Concerns summary Important letters from a clinician regarding a prisoner's prescription error and medication were neither acknowledged by the Governor nor passed to the prison healthcare team, posing a risk to prisoner welfare.

Concerns summary ACCT reviews in prison were frequently held without healthcare staff present, and relevant information from prior ACCTs was not consistently used when new ones were opened.

Concerns summary Detainees on the substance misuse unit received differential and inadequate care at night, lacking dedicated prison officers and equivalent attention compared to those on formal ACCTs.

Concerns summary The prison's SystmOne prescription system was difficult to use and incompatible, preventing medical staff from clearly verifying patient medication history, repeat prescriptions, and potential drug misuse.

Concerns summary Healthcare professionals in the immigration removal centre were unaware of or disengaged from essential ACDT documents, creating critical information gaps and putting detainees at risk.

Concerns 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.

Concerns summary Concerns remain that policies for medical emergencies in state custody, outside of Code Red/Blue scenarios, lack input from an emergency medicine expert, potentially missing cases requiring immediate hospital transfer.

Concerns summary There is a failure to share critical prisoner information between HMPPS and immigration detention facilities, alongside issues with the SystmOne records system's functionality and staff training.

Concerns summary Concerns exist regarding the content of police training for restraint and Appropriate Adult responsibilities. Criteria for identifying and transporting individuals to a place of safety under MHA 1983 also require review.

Concerns 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.

Concerns 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.

Concerns summary Clarification, redrafting, and improved guidance are needed for the PSI64/2011 section on first case reviews of ACCT assessments to ensure consistent and effective application across all prisons.

Concerns summary Prison healthcare staff lacked training and authorization to administer diazepam, despite having it available, indicating a systemic failure in emergency drug administration protocols for prisoners.

Concerns summary The jury identified errors and omissions in the care of an HMP Leeds inmate, which potentially contributed to his death by ligature.