State Custody related deaths

Concerns summary A dangerous prison culture of delaying cell entry when observation panels are obscured, assuming privacy rather than self-harm risk, persists despite repeated policy reminders and staff unawareness.

Concerns summary Police failed to share critical self-harm information with mental health services and contact handlers inadequately recorded severe welfare concerns, hindering appropriate assessment and response.

Concerns summary Procedural differences in observing detained persons during toilet visits between police and GeoAmey custody created an opportunity for prohibited items to be hidden. The subsequent search was also potentially inadequate.

Concerns summary Healthcare staff at HMP Chelmsford lack proficiency in navigating System One records to find critical past self-harm information, or are unaware of its importance during prisoner health assessments, indicating training deficiencies.

Concerns summary Inadequate national policy for sharing information on psycho-social support for substance misuse during prisoner transfers risks continuity of care and future deaths.

Concerns summary Imprisonment for Public Protection (IPP) prisoners face profound hopelessness and mental health suffering due to indefinite detention and lack of access to parole reviews or rehabilitative programs, increasing suicide risk.

Concerns summary An expired alcohol dependence policy, chaotic emergency care with faulty equipment and incorrect CPR, and insufficient training evidence demonstrate a cavalier attitude to patient safety.

Concerns summary There was a lack of planning for safe patient transport, particularly for a dementia patient, and an ineffective investigation into the death, hindering learning and future prevention.

Concerns summary There was a significant lack of inter-agency dialogue and learning following a severe incident, leading to persistent confusion regarding command primacy and effective response strategies during acute medical emergencies in prison.

Concerns summary The anti-ligature bedding failed, allowing ligature creation. Prison officers had inconsistent training on ACCT processes, first aid, and the Mental Capacity Act, leading to unclear responses during medical emergencies and conveyance.

Concerns summary The absence of clear national and local policies on managing illicitly brewed alcohol ("hooch") and governing prisoner-held medications creates significant safety risks within the prison estate.

Concerns summary Inadequate ACCT process training for new prison officers led to an incomplete understanding of observation requirements, including inconsistent timing and recording for vulnerable prisoners.

Concerns summary The prison's secreted item policy inadequately addresses ingestion, and the handover from other agencies removes constant supervision, compromising the duty of care for prisoners with concealed items.

Concerns summary Prison staff lack essential diabetes training and understanding of critical attacks. Non-24/7 healthcare and poor awareness among staff risk delayed care and future deaths for insulin-dependent prisoners.

Concerns summary The ACCT process at HMP Styal is ineffective for preventing self-harm, lacking therapeutic mental health input. The prison holds many complex patients requiring hospital-level care, with slow transfer processes, risking future deaths.

Concerns summary Officers chairing ACCT reviews at HMP Rochester failed to read all relevant documentation, leading to inaccurate risk assessments, and some did not understand how to properly complete support plan paperwork.

Concerns summary A critical buzzer/intercom system in the prison has been inoperable for years, preventing emergency warnings, and authorities are unwilling to repair or replace it.

Concerns summary Inadequate recruitment, retention, and training of prison and healthcare staff led to severe understaffing, restricted services, and fundamental failures in prisoner welfare, supervision, and basic safety protocols.

Concerns summary Severe systemic failures in release planning for a vulnerable, elderly prisoner, including delayed engagement, inadequate accommodation arrangements, and insufficient emotional support, resulted in a tragic outcome.

Concerns summary The Probation Service lacked policy and training for barricading incidents, approved premises had easily movable furniture and ligature points, agency staff CPR training was unchecked, and critical information sharing between prison and probation was ineffective.

Concerns summary There is no policy for welfare checks when initial interviews are missed, and changes in cell sharing risk are not promptly communicated to prisoners. Furthermore, probation staff failed to report critical disclosures, resulting in an uninformed suitability assessment.

Concerns summary Due to severe staff shortages, keywork sessions for prisoners were drastically reduced, potentially increasing risks for those in custody, despite guidance recommending weekly meetings.

Concerns summary There is a critical lack of specialist rehabilitation accommodation for women at high risk of self-harm, leading to ineffective post-release support. Probation officers also lack sufficient understanding of available housing options and appropriate release planning.

Concerns 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.

Concerns summary Unreasonable prison risk assessments led to a premature ACCT closure and incorrect observation levels without required consultation. A senior officer provided incorrect and misleading evidence, raising concerns about policy adherence and accountability.