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
Ian Brown
Partially Responded
2016-0200 26 May 2016 Milton Keynes
HMP Woodhill Minister for Prisons
Concerns summary (AI summary) Despite previous recommendations, HMP Woodhill has failed to rigorously implement strategies to reduce self-inflicted deaths, resulting in continued rises in suicide and self-harm due to inadequate ACCT case management.
Action Taken (AI summary) NOMS has introduced a monthly forum to monitor progress on actions taken in response to recommendations relating to recent deaths in custody, delivered case management training to 90% of managers who chair ACCT case reviews, and is implementing a system to provide each offender supported through the ACCT process with a designated case manager.
Sheldon Woodford
Historic (No Identified Response)
2016-0189 16 May 2016 Hampshire Central
HMP Winchester
Concerns summary (AI summary) Key safety documents (SASH) are not universally identifiable during reception, and officers receive insufficient training in ACCT processes for managing at-risk individuals.
Ronnie Olliffe
All Responded
2016-0224 15 May 2016 Mid Kent and Medway
HMP Rochester
Concerns summary (AI summary) There was a failure to issue a Code Blue appropriately, a lack of understanding about its emergency consequences, and a failure to use an available defibrillator.
Action Taken (AI summary) Following a failure to issue a Code Blue, all night staff at HMP&YOI Rochester were issued copies of PSI 03/2013 and signed to confirm understanding. A Notice to Staff was issued and pocket-sized cards explaining the codes were ordered for all staff, and a defibrillator demonstration was provided.
Ahmedreza Fathi
Partially Responded
2016-0173 5 May 2016 Leicester City and Leicestershire South
Leicestershire Partnership NHS Trust Northamptonshire Healthcare NHS Foundat… East Midlands Ambulance Service NHS Tru… +1 more
Concerns summary (AI summary) Healthcare complex case planning was inadequate and not updated, multi-disciplinary meetings lacked formalisation and information access, and a prior overdose was not investigated as a safeguarding opportunity.
Action Planned (AI summary) HMP Gartree revised local contingency plans and re-issued instructions in May 2016 to ensure all staff understand that they must not delay calling an ambulance in all cases where there are serious concerns about the health of an offender. The prison is also working with EMAS to ensure effective Joint working and consistency of approach in all the prisons, with a joint emergency response protocol expected by 31 July 2016. East Midlands Ambulance Service (EMAS) has formed a senior regional group to address issues relating to secure environments, such as prisons and secure mental health units. They also plan a meeting with secure environment teams to address access issues, ambulance activation protocols, and partnership working principles.
Shalane Blackwood
Historic (No Identified Response)
2016-0179 3 May 2016 Nottinghamshire
HMP Nottingham National Offender Management Service NHS England +1 more
Concerns summary (AI summary) The prison lacks adequate provision for complex health needs, has insufficient staff for prisoner regimes, faces rife NPS use, and has unclear decision-making tools and staff awareness for physical symptoms alongside mental health issues.
Derrick Rose-Fowler
Historic (No Identified Response)
2016-0153 21 Apr 2016 Shropshire, Telford and Wrekin
HMP Stoke Heath Ministry of Justice
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.
Luke Ayres
All Responded
2016-0148 15 Apr 2016 Birmingham and Solihull
Birmingham and Solihull Mental Health N…
Concerns summary (AI summary) Delays in emergency response were caused by a cut-off 999 call, a staff member providing ambulance information from a distance without current patient status, and paramedics not being immediately escorted to the ward.
Action Planned (AI summary) The trust has improvement measures in place including implementation of a single anti barricade system, replacement of 70 observation panels and piloting of a new clinical handover tool. The trust will also implement a more robust approach to Environmental and ligature risk assessments and extend the simulation of medical emergencies on wards.
Steven May
Partially Responded
2016-0109 16 Mar 2016 Nottinghamshire
NHS England HMP Ranby National Offender Management Service +5 more
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.
Lee Rushton
Historic (No Identified Response)
19 Jan 2016 Liverpool and Wirral
102 Petty France SW1H 9AJ The Secretary of State for Justice
Concerns summary (AI summary) There is a lack of clear policy and training regarding how ACCT care plans and mandatory reviews should integrate with Cell Sharing Risk Assessments requiring single cell occupancy for prisoner protection.
Imran Douglas
Partially Responded
2015-0446 29 Dec 2015 London Inner (South)
General Medical Council London Borough of Tower Hamlets National Offender Management Service
Concerns summary (AI summary) A more flexible, person-based system may be safer than the current rule-based system regarding the transition of duties from YOT/YJB to PMU at age 18. Also, there appeared to be a disconnection between Looked After Child pathway planning and Transition Planning.
Action Planned (AI summary) • Leeds City Council has been working to design a scheme which provides safe pedestrian assisted facilities across the Ring Road at this location and the neighbouring Coal Road junction. • Design considerations have been concluded and a final layout has been confirmed, which will be compatible with proposed future improvements planned at the Coal Road/ Ring Road junction and also longer term aspirations along this strategic corridor. • A Highways Board report is to be presented to the Chief Officer (Highways and Transportation) early in the New Year to seek formal funding approval to progress the junction improvement measures at the Ramshead Approach/ Ring Road junction.
Derek Thomas
Partially Responded
2015-0502 15 Dec 2015 County Durham and Darlington
CARE UK G4S GEOAmey +2 more
Concerns summary (AI summary) Prison reception procedures failed under extreme pressure, leading to suicide risk information being overlooked due to staffing issues. Additionally, there was poor communication and conflicting understanding between prison and escort staff regarding critical safety form procedures.
Noted (AI summary) The prison has implemented mandatory verbal handover of SASH form information from reception staff to healthcare staff. All staff working in reception must complete an online training course, managed by their line manager and monitored through the staff appraisal system. Nursing staff have been instructed to review all documents when completing reception screening, and staff have been reminded of the importance of ensuring all paperwork accompanies an individual. All initial healthcare assessments are undertaken by qualified mental health nurses, unless circumstances prevent this. Care UK is no longer the healthcare provider at HMP Durham. It will forward the concerns to heads of healthcare at other facilities where it interacts with GEO Amey and the prison service. GEOAmey provided refresher training to over 90% of their officers regarding the completion of Prisoner Escort Records (PER) and Self Harm and Suicide Warning Forms (SASH Forms), following concerns raised about procedures and training.
Daniel Byrne
Historic (No Identified Response)
14 Dec 2015 Milton Keynes
Ms Claire Murdoch, Chief Executive, Cen… Northwest London NHS Trust
Concerns summary (AI summary) There were repeated failures to identify and assess suicide risk in newly arrived prisoners, with nursing staff notably absent from initial health screenings and reviews.
Dean Boland
Partially Responded
2015-0486 25 Nov 2015 Birmingham and Solihull
Birmingham Community Healthcare NHS Tru… Birmingham Prison National Offender Management Service
Concerns summary (AI summary) Pervasive drug issues in the prison are exacerbated by a lack of officer awareness, poor multi-disciplinary communication, and insufficient drug administration checks. Inadequate cell searches, lack of overnight monitoring, and poor external security measures allow widespread drug use and concealment.
Action Taken (AI summary) Detox unit staff completed training on supervising opiate substitution medication, and awareness training is scheduled for completion in January 2016. Monthly strategy meetings are held to discuss drug misuse, and attendance from prison officers on B Wing is mandatory. Widespread testing for psychoactive substances as part of the MDT process is planned for April 2016.
Thomas Black
Historic (No Identified Response)
2015-0467 24 Nov 2015 Gwent
HMP Usk
Concerns summary (AI summary) Prison staff failed to seek timely medical advice for a clearly unwell prisoner, indicating a critical lapse in duty of care and health monitoring.
Richard Green
Partially Responded
2015-0456 2 Nov 2015 Cumbria
Ministry of Justice National Offender Management Service
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.
Kevin Forster
All Responded
2015-0453 28 Oct 2015 County Durham and Darlington
G4S National Offender Management Service
Concerns summary (AI summary) HMP Durham had a serious drug problem, but staff lacked awareness and training on overdose policies, leading to complacent responses, inadequate treatment plans, and delayed emergency calls for prisoners under the influence.
Action Taken (AI summary) Healthcare staff have been reminded of the importance of full and contemporaneous notes, and training has been provided on substance misuse; clinical guidelines are being developed for substance misuse issues, including a treatment plan template on SystmOne. Posters are planned for discipline staff areas, and training will be repeated to prison officers on emergency code allocation. All staff have signed to confirm their understanding of the Emergency Code Protocol, and managers have verified their awareness. Pocket-sized cards explaining the protocol have been issued, and the protocol is displayed in prominent areas and explained to new staff during onboarding; the protocol has been an agenda item at team meetings, and the issue has been addressed by the Deputy Governor and the Governor.
Carl Foot
Historic (No Identified Response)
2015-0447 26 Oct 2015 London Inner (North)
HMP Pentonville
Concerns summary (AI summary) Delayed prison cell bell responses, lack of a system to track bell activation times, and inadequate post-incident review contributed to a prisoner's death.
Samuel Gale
All Responded
2015-0454 23 Oct 2015 South Yorkshire (East)
HMP and YOI Doncaster
Concerns summary (AI summary) A prisoner's ACCT plan was closed without consulting crucial healthcare and management staff, suggesting a critical lapse in multi-disciplinary oversight for vulnerable individuals.
Action Planned (AI summary) Policy changes have been made so that only a manager grade can close an ACCT, and ACCTs cannot be closed unless the case review comprises at least two people and all actions on the CAREMAP have been completed; HMP & YOI Doncaster will seek to move to a case management model during 2016 whereby a nominated case manager manages a case load so that continuity of care is improved. NHS England is reviewing templates for first night screening and risk assessment as part of the deployment of a new Health & Justice Information System, with rollout expected from July 2016 to July 2017.
Liam Smith
Partially Responded
2015-0382 18 Sep 2015 Worcestershire
Governor HMP Hewell Worcestershire Health and Care Trust
Concerns summary (AI summary) Mandatory ACCT procedures for self-harm risk were not followed, critical medical information was poorly disseminated within the prison, and limited healthcare interaction with high-risk drug users led to missed warning signs.
Action Taken (AI summary) HM Prison and Probation Service has reiterated the professional obligation of clinical staff to review relevant parts of prisoner's notes and has changed practices relating to high risk drug users by implementing a follow up ledger to SystmOne within three working days of the detoxification programme ending.
Adil  Habib
Partially Responded
2015-0380 16 Sep 2015 London Inner (North)
HMP Pentonville London Ambulance Service NHS Trust National Offender Management Service
Concerns summary (AI summary) Lack of specific gate location information for prisons during 999 calls, compounded by London Ambulance Service's system not uniformly supporting alternative gate selection across all London prisons.
Action Taken (AI summary) HM Prison and Probation Service has completed a DVD covering principles of safe restraint, medical complications, and actions to take when prisoners conceal items in their mouths, which will be sent to all prison Governors by Christmas. The London Ambulance Service has augmented its computer system with additional gate information for HMP Pentonville and shared learning about confirming addresses when taking calls from prisons in a team talk.
Ian Emsley
Historic (No Identified Response)
8 Sep 2015 Exeter and Great Devon
HMP Exeter HMP Portland
Concerns summary (AI summary) Inadequate formal guidance for healthcare staff on assessing re-offending and escape risk contributed to delays in compassionate release or transfer decisions for terminally ill prisoners.
Andrew Frere
Historic (No Identified Response)
8 Sep 2015 South Yorkshire (East)
Equalities, Rights and Decency Group, T…
Concerns summary (AI summary) A national prison instruction for 24-hour doctor review is impracticable and ignored. Case managers also fail to read ongoing observations during ACCT reviews, risking missed critical information.
Craig Chappell
Historic (No Identified Response)
8 Sep 2015 East Riding and Kingston Upon-Hull
HMP HUMBER (EVERTHORPE SITE)
Concerns summary (AI summary) Inadequate information sharing and a lack of formal mechanisms for communicating family concerns hindered support. Prison staff also lacked sufficient guidance on supporting potential abuse victims, relying inappropriately on presentation.
Rubel Ahmed
Partially Responded
2015-0308 5 Aug 2015 Lincolnshire (Central)
Home Office Ministry of Justice
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.
Carl Smith
Partially Responded
2015-0298 24 Jul 2015 Exeter and Greater Devon
Dorset Health Care University NHS Found… HMP Exeter
Concerns summary (AI summary) Custodial and welfare checks for a prisoner on an ACCT and Methadone Stabilisation Programme were insufficient, and information sharing related to these checks was deficient.
Action Taken (AI summary) Dorset HealthCare NHS Trust implemented new policies and procedures to improve the quality of service in Devon Prisons. An education package has been put in place for all staff regarding substance misuse awareness.