State Custody related deaths

PFD Category
Reports: 357 Areas: 57 Earliest: Aug 2013 Latest: 8 Apr 2026

74% response rate (above 63% average). 58% of classified responses show concrete action taken. Reports rose 40% from 25 (2023) to 35 (2024).

Response Status
Responded 263 No Response 11 Historic 80 Pending 2
AI Classification
Action Taken 58%
Action Planned 27%
Noted 14%
Disputed 0%
Based on 401 classified responses
Reports by Quarter
PFD Reports
357 results
Timothy Shaw
Partially Responded
2018-0047 15 Feb 2018 Essex
Care UK Clinical Services Essex Partnership University NHS Founda… Farleys Solicitors LLP +2 more
Concerns summary (AI summary) Healthcare staff showed confusion regarding intelligence reports, communication between departments was poor, and systems for reducing illegal substances and managing referrals needed improvement. Record-keeping was also substandard.
Noted (AI summary) Care UK acknowledges receipt of the report but states they ceased providing healthcare at HMP Chelmsford on 26 May 2017 and therefore will not be filing a substantive response.
John Chapman
All Responded
2018-0007 11 Jan 2018 Lancashire
HMP Wymott
Concerns summary (AI summary) A critical lack of formal procedures for sharing prisoner self-harm and welfare alerts between prison reception staff and healthcare nurses during medical screenings created a risk of significant alerts being missed.
Action Taken (AI summary) All reception staff at HMP Preston have been given a copy of PSI 07/2015 and made it an objective to read and comply; revised suicide and self-harm prevention training is being rolled out, prioritising reception staff; emergency boxes with resuscitation aids are on all residential units, and all staff with prisoner contact will be issued resuscitation aids by June; contingency plans have been amended to ensure staff are informed about the manner of all non-natural deaths. The prison and healthcare services have agreed that PER forms will be passed to the reception nurse as a matter of routine, who must then document within the SystemOne record that the form has been received and considered; they are exploring incorporating this check into the record system as part of the existing reception health screen template.
John O’Meara
All Responded
2018-0012 10 Jan 2018 London (West)
HMP Wormwood Scrubs
Concerns summary (AI summary) Prison officers inconsistently followed Code Blue/Red procedures, delaying emergency response and Naloxone administration due to inadequate training. There's also an insufficient number of passive drug detection dogs to control Novel Psychoactive Substances.
Action Taken (AI summary) Regular notices to staff are published, signs are displayed in all offices and information about emergency response procedures is included in the induction for all new staff; notices have been attached to all cell doors in the First Night Centre; the London and Thames Valley regional search team is currently recruiting additional dog handlers to increase the service provided to prisons in the region, including HMP Wormwood Scrubs, which will be provided with a total of seven dog handlers, with both passive and active search and patrol dogs.
Craig Royce
Partially Responded
2017-0379 20 Dec 2017 Essex
Bindmans Solicitors Care UK Essex Partnership NHS Trust +2 more
Concerns summary (AI summary) A lack of a formal, robust documentary system for referring prisoners to mental health services meant reliance on unreliable telephone conversations, risking delays in crucial assessments.
Action Taken (AI summary) Since taking over prison healthcare services in 2017, Essex Partnership University NHS Foundation Trust has implemented a robust documentary system for referral of prisoners to mental health care, including widening the availability of a referral form to all prison staff.
Stephen Shaylor
Partially Responded
2017-0380 18 Dec 2017 Exeter and Greater Devon
Care UK Dorset Health Care University Home Office
Concerns summary (AI summary) Prison healthcare for detox inmates was "not fit for purpose" due to insufficient stabilisation places and inadequate night welfare checks. Intermittent observations are insufficient to detect self-harm, requiring continuous monitoring.
Noted (AI summary) Care UK clarified that night welfare checks are conducted by HCAs, with a nurse available for assistance, and that the nurse from the Integrated Substance Misuse Service reviews the welfare check list daily; they reiterate that ACCT documentation is the responsibility of prison staff and the welfare checks don't replace it, and that the MPCCC clinic is held weekly.
Mark Doyle
Partially Responded
2017-0375 18 Dec 2017 London Inner (North)
Care UK HMP Pentonville HM Prisons and Probation Service
Concerns summary (AI summary) Significant failings in ACCT case reviews, inadequate healthcare information sharing, and a lack of clear criteria for prisoner transfer decisions were identified. There is also no mandatory first aid training for existing prison officers.
Action Taken (AI summary) Care UK has reflected on the inquest and reviewed healthcare processes, embedding Local Operating Procedures (LOPs) with senior management audits, to ensure relevant risks and triggers are identified and shared with the prison; additionally, prisoners admitted to the Substance Misuse Unit will remain for a minimum of two weeks, with senior manager and clinical lead reviews before any moves.
Sidonio Teixeira
Historic (No Identified Response)
2017-0366 12 Dec 2017 Worcestershire
HMP Long Lartin
Concerns summary (AI summary) The adequacy of prison intelligence processes, including reporting and analysis, was questioned. A critical internal report on these issues was not shared with relevant staff, indicating a failure to learn lessons.
Christopher Talbot
Historic (No Identified Response)
2017-0427 29 Nov 2017 Preston and West Lancashire
HMP Preston HM Probation and Prison Service Ministry of Justice
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.
Jason Basalat
All Responded
2017-0423 27 Nov 2017 Milton Keynes
HM Courts and Tribunals Service Northamptonshire Police
Concerns summary (AI summary) Poor information sharing between police, magistrates' court, and prison meant the prison lacked critical details about a vulnerable prisoner's mental state, and a mental health assessment couldn't be arranged.
Action Planned (AI summary) Custody officers and staff have been reminded of guidance on completing Prisoner Escort Record (PER) forms and ensuring relevant documentation accompanies them. Contact will be made with the national police lead on Custody to suggest a review of the PER form. The court will liaise with criminal justice agencies, the Criminal Justice Liaison and Diversion Team, and Northamptonshire Healthcare NHS Foundation Trust to review procedures for sharing information about vulnerable adults remanded to prison. Legal advisers have been reminded to forward CPNI forms or suitably endorse warrants.
Robert Richards
Historic (No Identified Response)
2017-0406 20 Nov 2017 London Inner (West)
HMP Wandsworth St George’s Hospital
Concerns summary (AI summary) HMP Wandsworth suffered from pervasive bullying due to inadequate staff, poor communication, insufficient training, and inappropriate cell allocation. Critical issues also included inadequate medical training and supply restocking.
Vilhelmas Borkertas
Historic (No Identified Response)
2017-0342 31 Oct 2017 London Inner (North)
HMP Pentonville
Concerns summary (AI summary) A bisexual prisoner was improperly celled with a homophobic cellmate despite clear risk assessment information, raising concerns about placing inmates with conflicting profiles.
Mark Vagnoni
Partially Responded
2017-0286 11 Oct 2017 Bedfordshire & Luton
HMP Bedford HM Prison and Probation Service
Concerns summary (AI summary) Inadequate risk assessments and mental health input during "patrol state", unhelpful electronic record layouts, and missing transfer documentation for prisoners posed significant risks.
Action Taken (AI summary) All staff at HMP Bedford were reminded of the importance of considering all available information prior to changing a prisoner's location, with monthly checks to ensure accurate record keeping. Staff will refresh their knowledge of NOMIS and a standardized induction program for new staff will be implemented by December 2017.
Levi Cronin
Historic (No Identified Response)
2017-0287 6 Oct 2017 Suffolk
HMP Highpoint HM Prison and Probation Service NHS England
Concerns summary (AI summary) Concerns arose over inadequate information sharing between healthcare and prison staff, particularly regarding historical risk data. Poor recording of observable changes on prison wings also hindered effective dynamic risk assessments.
Sam Molyneux
All Responded
2017-0340 13 Sep 2017 Liverpool & Wirral
HM Prison & Probation Service
Concerns summary (AI summary) Old prison wings lacking anti-barricade doors delayed emergency access, and a prisoner with documented self-harm threats was not placed on an appropriate monitoring plan (ACCT).
Action Planned (AI summary) HM Prison & Probation Service will revise the ACCT form and PSI 64/2011 Safer Custody policy to direct staff to consider emergency access, including the presence of an anti-barricade door, when locating prisoners on ACCT. This will also be included in ACCT case manager training.
Sean Plumstead
All Responded
2017-0316 9 Aug 2017 Hampshire (Central)
Carillion HM Prison and Probation Services HM Prison Winchester
Concerns summary (AI summary) Winchester Prison has inadequate systems for storing electronic material and creating transcripts, leading to missing crucial evidence. This recurring issue raises a risk of future deaths due to poor record-keeping.
Action Planned (AI summary) HMP Winchester has taken on a temporary staff member to transcribe telephone calls, implemented a new protocol for information gathering, transcribed interview discs, and ordered a secure storage facility for documentation regarding any death in custody. The Head of Business Assurance is reviewing accounting systems and storage of internal investigation material. Carillion has contacted HMPPS and proposed a formal instruction for staff to undergo SASH training, is ready to issue a notice to site managers to make staff available, and suggested that HMPPS maintain a training record for Carillion staff. HMPPS has confirmed that all Carillion prisoner facing staff should be required to undergo training. The prison has issued notices to staff regarding emergency call bell response times and to prisoners about the misuse of call bells. The prison is also checking ECB response times daily and bidding for funding to upgrade the ECB system; nationally, a learning bulletin will be issued to staff on ECB importance and abuse in early 2018.
Sarah Reed
Partially Responded
2017-0238 28 Jul 2017 London (City)
Central and North West London NHS Trust HM Courts and Tribunals Service HM Prison and Probation Service +1 more
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.
Edwin O’Donnell
All Responded
2017-0258 13 Jul 2017 Liverpool & Wirral
HM Prison and Probation Services
Concerns summary (AI summary) Prison health reception screening failed due to lack of access to critical mental wellbeing documents and significant delays in follow-up screening. Additionally, probation staff lacked adequate ACCT training.
Action Taken (AI summary) The Senior Officer in reception now provides a copy of the Person Escort Record (PER) to healthcare staff and reception staff have been made aware of this process. The individual concerned has been reminded of the circumstances under which it is appropriate to open an ACCT, and suicide and self-harm training is being rolled out to all staff.
Jonathan Palmer
Partially Responded
2017-0173 31 May 2017 London Inner (West)
HMP Wandsworth Home Office
Concerns summary (AI summary) There was no effective system for families to provide crucial health information for prisoners, nor assurance of its dissemination. Ineffective control of contraband (Spice) inflow posed significant health risks within the prison.
Action Taken (AI summary) A Safer Custody Learning Bulletin has been issued regarding receiving emergency calls and sharing risk information from families, Samaritans, and others. HMP Wandsworth conducts searches of all visitors and prisoners after visits and uses various methods for prisoner searches, including a new body scanner. Mail and property are searched, and a policy on property was updated in 2016.
Daniel Dunkley
Historic (No Identified Response)
2017-0147 2 May 2017 Milton Keynes
HMP Woddhill
Concerns summary (AI summary) The report notes that three referrals were made for Mr Dunkley to undergo a full mental health assessment before his death.
Arthur Morley
Historic (No Identified Response)
2017-0106 4 Apr 2017 Buckinghamshire
HMP Grendon
Concerns summary (AI summary) The report indicated concerns but did not provide specific details on what matters gave rise to them, making it impossible to identify key safety issues.
Ondrej Suha
Historic (No Identified Response)
2017-0098 30 Mar 2017 Staffordshire (South)
National Offender Management Service
Concerns summary (AI summary) Prison officers lacked specific training for night shifts and basic resuscitation, hindering their ability to respond effectively to emergencies.
John Williams
Partially Responded
2017-0094 28 Mar 2017 London Inner (North)
Care UK HMP Pentonville National Offender Management Service +1 more
Concerns summary (AI summary) Inaccuracies in self-harm recording by a reception nurse and a missed second reception screen indicate potential training deficiencies and a need for improved referral systems.
Action Taken (AI summary) Care UK has reminded the nurse involved about giving evidence at an inquest and provided further support. The First Reception Health Screen template has been changed to include a mandatory field for mental health referrals, with electronic referrals made directly to the mental health in-reach team.
Valdas Jasiunas
Historic (No Identified Response)
2017-0062 8 Mar 2017 London (East)
Metropolitan Police
Concerns summary (AI summary) Custody risk assessments inadequately screen for alcohol dependency, and the computer system's design leads to frequent errors, further complicated by a lack of multi-language support for safety information.
Jack Portland
Partially Responded
2017-0049 21 Feb 2017 Buckinghamshire
Central and North West Hospital NHS Tru… HMP Woodhill Oxford Health NHS Trust
Concerns summary (AI summary) No specific concerns regarding future deaths were detailed in the provided text, only contact information.
Action Taken (AI summary) Extensive suicide and self-harm prevention training has been delivered to staff since 2015, new procedures have been introduced to improve ACCT management, prisoners will be able to register with a GP practice before leaving prison from July 2017, and future disclosure to the Coroner's Court will be done through GLD. The Section 17 leave form has been amended, and a new SOP for managing leave includes discussions with family. The Trust also reports on weekly monitoring processes and has introduced the appointment of a Named Professional to offer support and guidance to families.
Dean Saunders
Partially Responded
2017-0056 17 Feb 2017 Essex
Care UK Clinical Services National Offender Management Service NHS England +1 more
Concerns summary (AI summary) Serious systemic issues include a rigid protocol preventing mentally disordered individuals' transfer from police custody, unclear hospital transfer processes, and inadequate staff training in the ACCT process, compounded by insufficient psychiatric cover in prisons.
Action Planned (AI summary) NHS England states that Care UK circulated a document with contact details of medical staff who can sign Mental Health Assessment documents, and a new provider will deliver healthcare at HMP Chelmsford from May 2017 with greater access to psychiatrists. Essex Partnership NHS Trust has submitted its admissions protocol for regional review by the Secure Services Catchment Group for East of England and will inform the coroner of the outcome; it has also referred the issue of best practice in relation to the forensic pathway to the same group. Care UK developed a new Mental Health Pathway, formally signed off on 28 March 2017, and is rolling it out across all Care UK sites via mental health workshops to examine processes and quality of care provided.