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
Seweryn Glowinski
Historic (No Identified Response)
2014-0446 15 Oct 2014 Worcestershire
HMP Long Larkin
Concerns summary (AI summary) Serious communication breakdown between prison units, incorrect documentation due to "cutting and pasting" prisoner information, and senior staff unawareness of segregation policies for at-risk prisoners.
Vincent Oliver
All Responded
2014-0438 9 Oct 2014 Northumberland (North)
HMP Northumberland
Concerns summary (AI summary) A prison officer's failure to check a prisoner's well-being during unlocking, combined with a lack of recorded compliance with physical response requirements during roll checks, risks missed deaths.
Action Taken (AI summary) HMPS Northumberland has introduced a written system for recording wellbeing checks of prisoners throughout the day, with wing diaries amended to reflect the change.
Satheeskumar Mahatheaven
All Responded
2014-0412 19 Sep 2014 London Inner (North)
HMP Pentonville
Concerns summary (AI summary) Failures in information sharing, multi-agency communication procedures, and inadequate training contributed to an accident within prison services.
Action Taken (AI summary) HMP Pentonville and HMP Thameside have implemented local policies to ensure appropriate information sharing and effective communication between prison staff and healthcare providers. Community GP records are now routinely requested in all cases with health concerns, and all new healthcare staff are shown how to use the SystmOne electronic record system correctly.
Yohannes Kidane
All Responded
2014-0392 3 Sep 2014 Birmingham & Solihull
Birmingham and Solihull Mental Health T… Birmingham Prison
Concerns summary (AI summary) Insufficient night staffing on prison healthcare wards compromised effective ACCT observations and overall prisoner care. Additionally, staff were not taking breaks, impacting their wellbeing and the quality of care provided.
Noted (AI summary) NOMS reviewed the night staffing level for HMP Birmingham and found it acceptable, noting G4S's deployment of a Prison Custody Officer. They state that the Night Orderly Officer arranges cover for breaks, and additional staff are provided for prisoners under continuous supervision. The Trust has liaised with Birmingham Community Healthcare Trust and G4S to address staffing concerns and is considering options for staff breaks, including administrative duty sharing. They are engaging the commissioner regarding funding for an extra staff member and have met with G4S to discuss non-clinical duties.
Stephen Farrar
Partially Responded
2014-0386 29 Aug 2014 Milton Keynes
Ministry of Justice Secretary of State for Health
Concerns summary (AI summary) There was no formal risk assessment completed when Mr Farrar was first admitted to Woodhill Prison, despite risk factors; there is no formal risk assessment tool available in prisons.
1 response from Greater Manchester Police
Sean Brock
All Responded
2014-0381 8 Aug 2014 Milton Keynes
National Offender Management Service
Concerns summary (AI summary) A significant reduction in prison officer numbers at HMP Woodhill directly compromises prisoner safety and poses a risk to lives.
Noted (AI summary) HMP Woodhill staffing levels have been benchmarked and agreed upon, with ongoing local and national recruitment efforts to address vacancies. Information sharing between prison staff and contractors is a priority.
Edward Devlin
Partially Responded
2014-0335 22 Jul 2014 County Durham & Darlington
Care UK HMP Durham National Offender Management Service +1 more
Concerns summary (AI summary) Nurses reportedly slid medication, including dangerous drugs, under locked cell doors, leading to uncertainty about patient consumption, compromised dispensing records, and risks of drug trading or stockpiling for overdose.
Action Planned (AI summary) Care UK will develop a formal policy detailing the action required by nursing staff when they are unable to administer medication to a prisoner, for example due to a threat of violence.
Marcin Stoga
All Responded
2014-0576 21 Jul 2014 Oxfordshire
HMP Bullingdon
Concerns summary (AI summary) Crucial information regarding a prisoner's overdose history was not available during initial assessment. Furthermore, prisoners with mental health risks are not routinely or thoroughly assessed upon return from court, leaving significant gaps in their care and safety.
Action Planned (AI summary) HM Prison and Probation Service is trialling revised Prisoner Escort Records including a 'Red Flag' page to highlight key risk/vulnerability information. They also highlight existing protocols for screening prisoners returning from court for healthcare or self-harm issues.
Adam Williams
All Responded
2014-0324 14 Jul 2014 Staffordshire (South)
HMP Featherstone
Concerns summary (AI summary) Concerns raised regarding the need for improved emergency communication training for nursing staff and a more robust dynamic assessment process for prisoner restraint, with potential for further CCTV installation.
Action Taken (AI summary) HMP Featherstone now requires two healthcare staff to attend all health emergencies called over the radio. Duty Managers have received advice and guidance on emergency escorts, and this issue is regularly reviewed by the Senior Management Team.
Jake Hardy
Historic (No Identified Response)
2014-0305 30 Jun 2014 Manchester (West)
HM Youth Offenders Institute Hindley Ministry of Justice National Offenders Management Service +1 more
Concerns summary (AI summary) Vulnerable young persons with complex needs face increased self-harm and suicide risks in Youth Offender Institutions due to staff lacking adequate training and understanding.
Wilfred Aspinwall
Historic (No Identified Response)
2014-0283 25 Jun 2014 Liverpool
Prison and Probation Ombudsman
Concerns summary (AI summary) Healthcare provider at HMP Liverpool did not receive critical PPO and Clinical Review reports, hindering effective implementation of recommendations for prison fatalities.
Lloyd Butler
All Responded
2014-0281 25 Jun 2014 Birmingham & Solihull
West Midlands Police
Concerns summary (AI summary) A pervasive lack of professionalism, leadership, and appropriate training in the custody suite led to an unacceptable culture and inadequate control over staff behavior with vulnerable detainees.
Action Taken (AI summary) West Midlands Police instigated misconduct procedures against officers and staff involved, resulting in disciplinary sanctions. They have provided clear guidance on dealing with individuals arrested for being drunk and incapable, directing that they be treated as a medical emergency and taken directly to hospital.
Redmond Johnson
Historic (No Identified Response)
2014-0279 20 Jun 2014 Suffolk
Ministry of Justice NHS England
Concerns summary (AI summary) Prison healthcare lacked robust processes for gathering detainee medical history, conducting medication reviews, documenting test results, and assessing fitness for transfer, risking inadequate care for those with complex needs.
David O’Garro
Historic (No Identified Response)
2014-0270 16 Jun 2014 London Inner (North)
HMP Pentonville
Concerns summary (AI summary) The report cites that a nurse did not complete a cell sharing risk assessment and staff lacked clarity and shared understanding regarding the assessment process for prisoners with epilepsy.
Matthew Purser
Historic (No Identified Response)
2014-0568 30 May 2014 Swansea & Neath Port Talbot
HMP Swansea MINISTRY OF JUSTICE National Offender Management Service
Concerns summary (AI summary) A prison doctor lacked ACCT training, ACCT trigger event documentation was subjective and lacked detail for accurate assessment, and procedures for obtaining community mental health records were unclear.
Kevin Scarlett
All Responded
2014-0174 15 Apr 2014 Milton Keynes
National Offender Management Service
Concerns summary (AI summary) The prison service and healthcare failed to assess the deceased's suicide risk, as staff lacked access to proper risk assessment tools or protocols.
Action Taken (AI summary) HMP Woodhill reviewed the local ACCT process in December 2013, revised the case review process, and issued guidance to staff. A governor grade is appointed to manage the case of each prisoner subject to the ACCT process who is assessed as having complex needs.
David Oldfield
All Responded
2014-0117 14 Mar 2014 West Yorkshire (East)
West Yorkshire Police Force
Concerns summary (AI summary) Concerns were raised about the appropriateness and justification of tasering the deceased, given discrepancies in officer accounts. Unjustified tasering unnecessarily increases the risk of serious injury or death.
Noted (AI summary) West Yorkshire Police acknowledge the concerns raised, particularly regarding officer accounts, and state that the IPCC was informed. They also offer a visit to their training facilities to demonstrate Taser training and usage.
Andrew Hall
Partially Responded
2014-0122 12 Mar 2014 Teesside
National Offender Management Service North Tees and Hartlepool NHS Trust Tees, Esk and Wear Valleys NHS Foundati…
Concerns summary (AI summary) Inadequate communication and documentation of mental health risks, failure to administer prescribed medication, and insufficient patient observation within the prison healthcare unit were identified. Training gaps for staff in risk assessment and ACCT procedures also contributed to concerns.
Action Taken (AI summary) Cameras have been removed from cells in the healthcare centre and any prisoner assessed as requiring high levels of observation is located in a constant observation cell. A system is now in place to ensure post-closure reviews of ACCTs take place within seven days, and a local policy for an additional review after one month has been introduced.
Christopher Shapley
Historic (No Identified Response)
2014-0121 11 Mar 2014 Cardiff & the Vale of Glamorgan
HM Prison Cardiff Home Office
Concerns summary (AI summary) Critical medical and self-harm risk information from police custody failed to transfer securely to the prison via the PER form, leading to inadequate assessment and observation of the prisoner.
Lee MacPherson
Historic (No Identified Response)
2014-0097 3 Mar 2014 London (West)
HMP Wormwood Scrubs Metropolitan Police National Offender Management Service +1 more
Concerns summary (AI summary) Delayed police risk assessments and a lack of common understanding between escort and prison staff regarding critical handover documentation posed significant safety risks during transfers.
Lee Curran
Historic (No Identified Response)
2014-0079 25 Feb 2014 Manchester (West)
Department of Health and Social Care HMP-YOI Forrest Bank Ministry of Justice +2 more
Concerns summary (AI summary) PPO recommendations for high cholesterol and loss of consciousness protocols were not fully implemented, with NICE guidelines ignored by doctors. Additionally, prison staff lacked training in accurate medical note-taking, leading to incorrect entries.
Amy Friar
Historic (No Identified Response)
2014-0051 3 Feb 2014 Surrey
Ministry of Justice
Concerns summary (AI summary) The absence of universal emergency codes across the prison estate creates confusion for transferring staff, risking delays in emergency response.
Zeeyad Hamadi
Partially Responded
2014-0014 13 Jan 2014 County Durham & Darlington
Department of Health and Social Care National Offender Management Service
Concerns summary (AI summary) Inadequate patient weighing and poor medical record-keeping within the prison were noted. There was limited liaison between prison and hospital staff, confusion over prisoner private healthcare policies, and delays in securing bed watch cover.
Action Planned (AI summary) The Secretary of State acknowledges the concerns and states that the National Offender Management Service (NOMS), NHS England and Public Health England (PHE) are due to meet to discuss governance arrangements for considering prisoner's requests for private treatment.
Billy Paul Thomas Salton
Partially Responded
2014-0002 6 Jan 2014 Manchester (South)
GEO AMEY MEDACS Greater Manchester Police
Concerns summary (AI summary) GMP policy of not staffing the Prisoner Processing Unit overnight leads to unnecessary and prolonged custody times for individuals awaiting interview.
Action Planned (AI summary) Medacs Healthcare has implemented measures to ensure staff are aware of and have access to Medacs policies and procedures. They are also reviewing the electronic MedacsFME system to include screening tools and dropdown boxes that will prevent sections from being completed. Greater Manchester Police acknowledge delays in processing detainees due to staffing limitations. They are currently reviewing roles in custody and looking for a system that matches or improves coverage of CCTV and also provides greater accountability.
Adrian Johnson
Partially Responded
2013-0364 20 Dec 2013 London (Inner South)
HMP Belmarsh National Offender Management Service NHS England
Concerns summary (AI summary) The coroner noted that initial screening did not assess for tobacco withdrawal, ACCT reviews lacked healthcare input, and there was a lack of consistency in case management, with no handover from case manager to case manager.
Action Planned (AI summary) NOMS and NHSE will give further consideration to the extent to which screening processes should identify tobacco dependence and potential withdrawal issues. ACCT refresher training will reinforce that prisoners subject to ACCT procedures should be located in segregation units only in exceptional circumstances.