State Custody related deaths

Action Planned (AI summary) HMPPS has initiated discussions with BT to explore the feasibility of monitoring call volumes as a potential indicator of heightened suicide/self-harm risk as part of an ongoing development project. They emphasize that any technical solution would be an additional tool to their existing holistic approach, including ACCT and the Listener scheme.

Action Planned (AI summary) HMPPS is undertaking a cell design review to explore different materials that meet fire safety and anti-ligature requirements for bedding, expected to conclude at the end of 2026. To improve first-on-scene care, HMPPS have with St John Ambulance created a set of bespoke first-on-scene videos for Prison Officers and frontline staff.

Action Planned (AI summary) A Practice Development Nurse (PDN) was appointed in September 2024 to ensure healthcare staff remain current with training and guidance, and the Quality Manager has reviewed and updated policies, communicating their locations to all staff members. SECAmb has several actions planned, including: establishing a Prisons Task and Finish Group, communicating the move away from 'Code Red/Blue' terminology, ensuring clarity around primacy of care, and undertaking a learning needs analysis regarding restraint implications. They will also review the Surrey Safeguarding Adults Board Care of Prisoners into Acute Hospitals guidance. HMPPS has reminded staff at HMP Elmley to request healthcare assistance immediately during any unplanned restraint and Oxleas staff have been reminded of their contractual requirement to remain with the individual throughout the medical emergency. NHS England Health & Justice guidance has been shared with Use of Force Coordinators and will be included in the new HMPPS framework and guidance.

Action Planned (AI summary) HMP Birmingham will update its Secreted Items Policy to include guidance for staff on actions to take when a prisoner has ingested an item. They will also issue guidance to staff to ensure a fully documented risk assessment is completed for any prisoner entering the establishment under constant supervision.

Action Planned (AI summary) NHS England highlights the 'We Are Prison Nurses' campaign and nursing preceptorship to address workforce demands and notes several platforms locally to enable effective sharing of information. Findings will be tabled at a future NHS England Health and Justice Delivery Oversight Group. All Health and Justice related Reports to Prevent Future Deaths are shared and discussed at the HJDOG, and assurance is sought from regions where learning and action is identified. Serco has committed to undertaking a 'lessons learned' exercise with the MOJ and Sodexo, facilitated by the Cabinet Office, to identify aspects of the prison transition that went wrong and produce a Transitions Playbook for future use. Sodexo highlights its compliance with Early Days In Custody PSI, use of SASH forms, ACCT training, and CMS for information sharing. Post-inquests, Sodexo ringfenced key safety tasks and safer custody staff to address resourcing pressures. Nottinghamshire Healthcare NHS Foundation Trust has enhanced Executive led oversight and assurance reviews for Offender Health, mandated daily checks of electronic patient records, and requires attendance at ACCT case reviews. They have also improved handover processes and email communication. HMPPS took over management of HMP Lowdham Grange on 1 August 2024. Since then, HMPPS has increased safer custody staffing levels, established a senior management team with relevant experience, and reviewed the ACCT process. Additionally, HMPPS has disseminated existing guidance regarding document retention and will review its approach to making formal admissions at inquests.

Action Planned (AI summary) HMPPS has finalised Barricade Guidance, which will be issued to all approved premises staff on 1st August 2025, with staff required to acknowledge receipt by the end of September 2025. A new digital referral process is in place to pull information from prison and probation systems, and Oasys is used by Probation Practitioners to assess risk.

Action Planned (AI summary) Practice Plus Group has forwarded the PFD report to TPP (SystmOne provider) regarding the possibility of implementing a tick-box to confirm review of care plans. They will continue to audit ACCT reviews and collaborate with the prison for updated ACCT training for staff, and have already trained 78% of clinical staff. The Trust has revised its Local Operating Procedure for ACCT attendance and developed a Quality Improvement Plan. The Quality and Standards meeting will monitor ACCT training completion and improvements in record keeping. HMPPS will review local procedures regarding constant supervision at Eastwood Park within a month, and the national Safety Group is developing further guidance on constant supervision for prisons by the end of March 2026. Four ligature-resistant cells are planned to be in use shortly.