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
Margaret Atkinson
Partially Responded
2017-0021 30 Jan 2017 County Durham and Darlington
G4S National Offender Management Service Tees, Esk and Wear Valley NHS Trust
Concerns summary (AI summary) Concerns were raised about the difficulty in describing and assessing risk from unusual prisoner behaviour, potentially leading to its normalisation and overlooking signs of increased risk.
Action Planned (AI summary) The prison Mental Health services are using more specific language than "ligature" to describe observations, discussed in team meetings. The Trust will work with partners to agree and promote a guidance document within the NE prison cluster.
Mark Lilliott
Historic (No Identified Response)
2016-0453 16 Dec 2016 Liverpool and Wirral
HMP Liverpool
Concerns summary (AI summary) Delays in accessing a radio-equipped senior officer for emergency assistance within the prison, exacerbated by noise on the wing, could critically impede swift responses in future emergencies.
Simon Turvey
Historic (No Identified Response)
2016-0480 13 Dec 2016 Milton Keynes
National Offender Management Service Prison and Probation Ombudsman
Concerns summary (AI summary) The prison failed to inform family members how to report welfare concerns, potentially leading to missed suicide risk factors for detainees.
Tedros Kahssay
Partially Responded
2016-0437 6 Dec 2016 London Inner (North)
Care UK HMP Pentonville National Offender Management Service
Concerns summary (AI summary) Inadequate information transfer to prison healthcare, flawed nurse reception screening lacking objective analysis, and emergency response staff having insufficient understanding of medical emergency protocols.
Action Taken (AI summary) Care UK has changed the reception screening template to include mandatory PER review, seeks consent for GP records during screening, and reinforced Code Red/Blue training with staff and displayed posters. All clinical staff receive mandatory ILS training, and guidance on resuscitation with rigor mortis present has been circulated.
Matthew Russell
Partially Responded
2016-0430 27 Nov 2016 Surrey
Central and North West London NHS Trust HMP High Down Ministry of Justice
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.
Richard Walsh
All Responded
2016-0377 25 Oct 2016 London Inner (South)
DAC Beachcroft LLP Department of Health and Social Care Hampshire County Council +3 more
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.
Michelle Barnes
Historic (No Identified Response)
24 Oct 2016 County Durham and Darlington
NOMS, Prison Service, Equality Rights a…
Concerns summary (AI summary) Prison officers failed to initiate an ACCT process for a highly distressed prisoner, opting for a vague "offer support" note without a clear action plan, despite significant emotional risk.
Roy Hoey
All Responded
2016-0360 13 Oct 2016 Liverpool and Wirral
National Offender Management Service
Concerns summary (AI summary) Concerns arose from staff confusion regarding the interpretation and application of safer custody guidance, specifically when to open an ACCT plan, requiring clarification on mandatory assessment before initiation.
Action Planned (AI summary) NOMS acknowledges potential confusion regarding ACCT guidance and will resolve this in the revision of PSI 64/2011, due for completion by the end of April 2017; the revised version will be easier for staff to read and understand.
Wayne Cornlouer
All Responded
2016-0356 12 Oct 2016 Dorset
HMP Portland
Concerns summary (AI summary) An emergency coding system for medical emergencies was not initially in Night Orders, raising concerns if all staff are now aware of its recent inclusion and proper use.
Action Taken (AI summary) A notice to staff was re-issued on 28 September 2016 reminding staff about emergency codes and ambulance requests; the local emergency code protocol has been distributed and displayed. The induction programme for new staff is being updated to include guidance on the local emergency protocol and all existing staff will receive a personal briefing.
Calam Atour
Historic (No Identified Response)
2016-0461 12 Oct 2016 Wiltshire and Swindon
National Offender Management Service
Concerns summary (AI summary) Chronic understaffing in the prison system compromises officer safety and prisoner welfare. The method for determining staffing levels also fails to account for the specific risks posed by the inmate population type.
Haydn Burton
Partially Responded
2016-0346 4 Oct 2016 Hampshire (Central)
HM Prison Service Samaritans
Concerns summary (AI summary) Prison staff failed to implement ACCT plans effectively and observations were inadequate. Confidentiality rules for Listeners were unclear regarding active suicide plans, and the NOMIS database inadequately records past ACCT information.
Action Taken (AI summary) HMP Winchester is providing local ACCT refresher training and Safety Awareness training, including lessons learned from previous deaths in custody. Wing Supervising Officers are informed of ACCT post closure reviews, and Case Managers have been reminded to update NOMIS case notes following an ACCT case review.
Liam Lambert
Partially Responded
2016-0335 20 Sep 2016 Leicester City and Leicestershire South
HMP YOI Glen Parva Secretary of State for Justice National Offender Management Service
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.
Warren Sampson
Partially Responded
2016-0320 6 Sep 2016 Essex
Care UK Family Solicitors HMP
Concerns summary (AI summary) Prison healthcare lacked consistent input in ACCT reviews and a follow-up process for missed screenings. Officers were also not adequately familiar with local directives.
Action Taken (AI summary) Discipline staff now email healthcare each day with the ACCT reviews they are intending to hold and invite the appropriate healthcare professional to input into the process. A Second Health Screen is undertaken within 72 hours of an inmate arriving to ensure matters such as consent for obtaining GP records has been sought.
Peter Lawrence
Historic (No Identified Response)
2016-0314 30 Aug 2016 Cambridgeshire and Peterborough
National Offender Management Service
Concerns summary (AI summary) The initial screening process for new prisoners lacked a robust method to identify and comprehensively record less obvious risk factors, particularly with limited background information.
Stephen St Clair
Historic (No Identified Response)
2016-wp25358 12 Aug 2016 Isle of Wight
Ministry of Justice National Offender Management Service
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.
Thomas Jordan
Historic (No Identified Response)
10 Aug 2016 West Yorkshire (East)
Her Majesty's Prison, Leeds The Leeds Teaching Hospitals NHS Trust
Concerns summary (AI summary) Communication failures between the hospital and prison healthcare resulted in continued administration of a discontinued drug, as discharge information was not promptly reviewed by prison staff.
Thomas Jordan
Partially Responded
2016-0287 10 Aug 2016 Yorkshire West (East)
Head of Healthcare, HMP Leeds Medical Director, Leeds Teaching Hospit…
Concerns summary (AI summary) Communication breakdown and failure to review discharge correspondence at the prison led to continued, incorrect drug administration after hospital clinicians requested discontinuation. Electronic discharge summaries could prevent such errors.
Action Planned (AI summary) Leeds Teaching Hospital has agreed to issue an electronic summary with all patients who transfer back to HMP Leeds following discharge. IT personnel from both the Hospital and Care UK will create a pathway to ensure all summaries are appropriately shared, and written summaries are provided in sealed envelopes in the meantime.
Terence Adams
Partially Responded
2016-wp25340 26 Jul 2016 London Inner (North)
Care UK HMP Pentonville
Concerns summary (AI summary) Inadequate checking and sharing of prison risk assessments, healthcare staff unawareness of risk score protocols, and failure to follow up on missed appointments contributed to a lack of care.
Action Planned (AI summary) Care UK will remind staff to check they have had sight of the core record and any accompanying information including the PER, relating to history, index offence, sentence status, clinical history and possible warnings. They have also agreed that the prison Governor will automatically receive (redacted) copies of RCAs going forward.
Olawale Adelusi
Historic (No Identified Response)
22 Jul 2016 London (West)
METROPOLITAN POLICE SERVICE
Concerns summary (AI summary) There was no effective system to transmit critical information regarding a detained person's self-harm risk and mental health, as detailed observations of distress were not included in formal handover documents.
Michael Williams
All Responded
2016-0245 11 Jul 2016 Leicester City and Leicestershire South
HMP Leicester
Concerns summary (AI summary) Prison staff missed mandated observations and used predictable intervals for checks. There was an inappropriate delay in responding after a cell observation panel was blocked, indicating a lack of clear training.
Action Taken (AI summary) HMP Leicester reminded staff about conducting observations at unpredictable times, management checks are in place, ACCT documents are quality assured, the contingency plan was revised, and staff were trained to intervene quickly if the observation panel has been blocked.
John Betteridge
Historic (No Identified Response)
2016-0238 30 Jun 2016 County Durham and Darlington
G4S National Offender Management Service NHS England +1 more
Concerns summary (AI summary) Prison healthcare staff and a GP lacked or had insufficient ACCT training, resulting in non-adherence to mandatory ACCT procedures and indicating a clear, ongoing training need.
Beverley Devanney
Historic (No Identified Response)
2016-0485 24 Jun 2016 West Yorkshire (West)
West Yorkshire Police
Concerns summary (AI summary) Police officers lacked formal training for handling complex situations like Miss Devanney's, raising concerns about appropriate responses in similar future circumstances.
Anthony Fraser
All Responded
2016-0225 8 Jun 2016 South Yorkshire (East)
HMP Lindholme
Concerns summary (AI summary) Summary medical information was not conveyed to the receiving A&E department upon transfer, and there is no system for ensuring such information is sent; a system needs to be implemented to convey such information for every inmate transferred with an acute illness.
Action Taken (AI summary) Following concerns raised, the Trust co-authored a procedure with HMP Lindholme to convey summary medical information to A&E departments during inmate transfers, and the procedure has been issued to staff and is now in operation; a review of compliance will be undertaken.
Steven Trudgill
Historic (No Identified Response)
2016-0210 6 Jun 2016 Suffolk
Ministry of Justice
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)
Ministry of Justice NHS England
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.